[Senate Hearing 109-612]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 109-612

                   ALL-HAZARDS MEDICAL PREPAREDNESS 
                              AND RESPONSE

=======================================================================

                                HEARING

                                 OF THE

      SUBCOMMITTEE ON BIOTERRORISM AND PUBLIC HEALTH PREPAREDNESS

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                                   ON

        EXAMINING ALL-HAZARDS MEDICAL PREPAREDNESS AND RESPONSE

                               __________

                             APRIL 5, 2006

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                   MICHAEL B. ENZI, Wyoming, Chairman

JUDD GREGG, New Hampshire            EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee                CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
RICHARD BURR, North Carolina         BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia              JAMES M. JEFFORDS (I), Vermont
MIKE DeWINE, Ohio                    JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada                  PATTY MURRAY, Washington
ORRIN G. HATCH, Utah                 JACK REED, Rhode Island
JEFF SESSIONS, Alabama               HILLARY RODHAM CLINTON, New York
PAT ROBERTS, Kansas

               Katherine Brunett McGuire, Staff Director
      J. Michael Myers, Minority Staff Director and Chief Counsel

                               __________

      Subcommittee on Bioterrorism and Public Health Preparedness

                 RICHARD BURR, North Carolina, Chairman

JUDD GREGG, New Hampshire            EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee                CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
MIKE DeWINE, Ohio                    BARBARA A. MIKULSKI, Maryland
JOHN ENSIGN, Nevada                  JEFF BINGAMAN, New Mexico
ORRIN G. HATCH, Utah                 PATTY MURRAY, Washington
PAT ROBERTS, Kansas                  JACK REED, Rhode Island
MICHAEL B. ENZI, Wyoming (ex 
officio)

                     Robert Kadlec, Staff Director
                David C. Bowen, Minority Staff Director

                                  (ii)


















                            C O N T E N T S

                               __________

                               STATEMENTS

                        WEDNESDAY, APRIL 5, 2006

                                                                   Page
Burr, Hon. Richard, Chairman, Subcommittee on Bioterrorism and 
  Public Health Preparedness, opening statement..................     1
Agwunobi, John, M.D., assistant secretary for health, U.S. 
  Department of Health and Human Services; Ellen Embrey, deputy 
  assistant secretary of Defense for Force Health Protection and 
  Readiness, director, Deployment Health Support, U.S. Department 
  of Defense; and Lawrence Deyton, M.D., chief public health and 
  environmental hazards officer, U.S. Department of Veterans 
  Affairs........................................................     3
Inglesby, Thomas V., M.D., chief operating officer and deputy 
  director, Center for Biosecurity, University of Pittsburgh 
  Medical Center; Richard Serino, chief of department, Boston 
  Emergency Medical Services; Eddy A. Bresnitz, M.D., deputy 
  commissioner and state epidemiologist, Public Health Services 
  Branch, New Jersey Department of Health and Senior Services, on 
  behalf of the Council of State and Territorial Epidemiologists; 
  and Rob Gougelet, M.D., director of emergency preparedness, 
  Dartmouth-Hitchcock Medical Center.............................    22
    Prepared statements of:
        Dr. Inglesby.............................................    22
        Dr. Bresnitz.............................................    31
        Dr. Gougelet.............................................    33

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Response to Questions of Senator Burr by:
        Dr. Serino...............................................    43
        Ms. Embrey...............................................    45

                                 (iii)











 
                   ALL-HAZARDS MEDICAL PREPAREDNESS 
                              AND RESPONSE

                              ----------                              


                        WEDNESDAY, APRIL 5, 2006

                                       U.S. Senate,
            Subcommittee on Bioterrorism and Public Health 
             Preparedness, Committee on Health, Education, 
                                       Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:06 a.m., in 
Room SD-430, Dirksen Senate Office Building, Hon. Richard Burr, 
chairman of the subcommittee, presiding.
    Present: Senators Burr, Hatch, and Harkin.

                   Opening Statement of Senator Burr

    Senator Burr. Good morning. I know we are going to be 
joined periodically by other members of the subcommittee, but I 
do want to go ahead and get started for the sake of everybody's 
time.
    I want to thank all of our witnesses, both panels, for 
taking the time to come here to share valuable information as 
we attempt to reauthorize the bioterrorism and public 
preparedness bill. I want to acknowledge the incredible support 
that Senator Enzi and Senator Kennedy have shown to the effort, 
and I think this is truly bipartisan at every level as we begin 
to wade through where we are today, and more importantly, where 
we need to go tomorrow.
    This roundtable continues to advance our discussions 
concerning the reauthorization of the Public Health, Security, 
and Bioterrorism Preparedness and Response Act of 2002. This 
legislation moved the country in the right direction and 
improved our public health and medical preparedness. However, 
because of the growing diversity of threats, we need to 
continue the progress to increase the momentum and refine our 
effort.
    An effective medical response to disasters requiring 
Federal medical assets relies on a preestablished partnership, 
coordination at Federal, State, and local levels. This 
partnership must be adaptable enough to respond to all-hazard 
medical disasters with well-trained, well-equipped, and rapidly 
deployable assets.
    As you all know firsthand, the response to disasters begins 
at the local level. It is our responsibility at the Federal 
level to support local and State medical capabilities by 
providing integrated additional personnel, logistics support, 
and operational proficiencies to assist in caring for victims 
of a disaster, particularly in cases where the local resources 
have been overwhelmed. State and local government responders 
should know who to call at the Federal Government to get help. 
Right now, it is not clear who is in charge. That is something 
we definitely plan on addressing in this reauthorization.
    Finally, we need to think systematically and collectively 
about how best to develop surge capacity within the U.S. health 
care delivery system.
    I look forward to hearing from each one of our witnesses 
today regarding the experiences they have. I know all bring a 
different perspective to the table and this will not be the 
last hearing or roundtable that the committee has, but I 
believe that from a time line standpoint, we have got to begin 
to firm up some draft legislation and we will do that in a 
bipartisan fashion with the full and open knowledge of the 
agencies that are affected in hopes that we can, at the end of 
the day, find consensus not just in direction, but in details. 
It is my belief that that is one of the single most important 
things that this Congress will deal with as we conclude the 
109th Congress.
    At this time, I would like to introduce our first panel. 
Our first panelist today is Assistant Secretary for Health at 
the Department of Health and Human Services, Dr. Agwunobi. As 
many times as I have said that, you wouldn't think I would get 
tripped up. Until recently, he was Florida's Secretary of 
Health and brings invaluable operational experience to an 
important job at HHS. Doctor, we welcome you today.
    In addition, Ms. Ellen Embrey is the Deputy Assistant 
Secretary of Defense for Force Health Protection and Readiness 
at the Department of Defense. She leads the Defense department-
wide efforts to develop and implement policies, programs, and 
activities relating to force health protection, national 
disaster support, and medical readiness. Ellen, welcome.
    And last but not least, Dr. Lawrence Deyton is the Chief 
Public Health and Environmental Hazards Officer at the Veterans 
Health Administration within the Department of Veterans 
Affairs. Before accepting his present position, he worked at 
the National Institute of Allergy and Infectious Disease at NIH 
and we certainly welcome you, as well.
    I will go in the order that I introduced and make available 
to you any opening statement you would like to make. I would 
also at this time ask unanimous consent that all members be 
allowed to submit opening statements for the record and 
questions to the witnesses and would ask all our panelists 
today to make themselves available for those written questions, 
as well. Without objection, so ordered.
    Doctor.

  STATEMENTS OF JOHN AGWUNOBI, M.D., ASSISTANT SECRETARY FOR 
  HEALTH, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; ELLEN 
EMBREY, DEPUTY ASSISTANT SECRETARY OF DEFENSE FOR FORCE HEALTH 
PROTECTION AND READINESS, DIRECTOR, DEPLOYMENT HEALTH SUPPORT, 
 U.S. DEPARTMENT OF DEFENSE; AND LAWRENCE DEYTON, M.D., CHIEF 
     PUBLIC HEALTH AND ENVIRONMENTAL HAZARDS OFFICER, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    Dr. Agwunobi. Thank you, Senator. To save time, I will keep 
my comments very short. I will start by thanking you, sir, for 
this opportunity, this honor that you present us here today to 
have this discussion. I should also state that your leadership 
in this particular area is very clear and very well known and I 
thank you.
    Secretary Michael Leavitt and I have talked often and 
frequently on this subject and have traveled the Nation in 
recent days visiting almost every State as we talk about 
pandemic influenza preparedness. But in each of those settings, 
we have focused on some of the same things that you have just 
mentioned, sir, related to the fact that it needs to be an all-
hazards approach, that although local and State governments 
must always be a focus of preparedness for emergencies and all-
hazard-type events, that the Federal Government does play a 
very critical and clear role as we move forward.
    I thank you for this opportunity, sir, and look forward to 
the conversation.
    Senator Burr. Ellen.
    Ms. Embrey. Thank you again for the opportunity to be here. 
I have a written statement, overview statement that was 
prepared, and I would like to submit that for the record to 
save time so we can actually have a dialogue in the areas of 
your interest.
    Senator Burr. Great. Thank you.
    Dr. Deyton.
    Dr. Deyton. Senator, thank you for asking us here. I will 
start out just with two personal comments. I thank you for 
pronouncing my last name correctly. My daddy's family is from 
Yancy County, North Carolina, and you are the only person who 
has said it right the first time, and thank you for that, sir.
    Senator Burr. It is a shame I messed his name up right from 
the beginning, isn't it?
    [Laughter.]
    Dr. Deyton. Second, sir, the table situation is 
uncomfortable for those of us on the administration side. We 
wanted to be at the same table, so we apologize for not sitting 
together.
    I will dispense with my remarks, too, and just look forward 
to your questions, sir.
    Senator Burr. Great. I thank all of you.
    Let me just say, we have got a huge task. I referred to 
this in the staff meeting, that the task before us is somewhat 
like herding cats because everybody has a specific area of 
responsibility, and expertise within the Federal Government. I 
think it is safe to say that as we have gone through this 
process for now almost a year and a half on different pieces 
that we feel need to be in place, the one question that always 
comes up is, who is in charge? Who needs to be designated as 
the individual, area, agency?
    It is the plan of the subcommittee that in the next 60 
days, we will go to the Gulf Coast to explore the health 
infrastructure, and try to talk more in-depth about lessons 
learned. What worked? What didn't work? Why was the DOD's role 
in Katrina so important? Had it ever been planned for from the 
standpoint of local response? If not, why not? If it was 
crucial in the aftermath of that natural disaster, then how 
should we, in the future, plan for it? What were the 
differences that existed between Mississippi and Louisiana? Why 
could you have two States side by side with what I perceive to 
be totally different outcomes from a standpoint of the response 
to this disaster?
    I have tried to keep everybody focused on the fact that we 
would make a true mistake here if our effort was not an all-
hazards approach. I think we naturally sometimes get stovepiped 
within government. We get focused on the threat du jour and our 
imagination isn't great enough to realize that there is another 
threat around the corner. We just don't know the name of it and 
we don't know the impact of it.
    I truly believe that it is time that we design a model that 
not only handles today's threats that we know about, but begins 
to address a blueprint that can handle tomorrow's threats 
without requesting that the experts come back to the Hill and 
we legislatively contort ourselves to try to accommodate what, 
in fact, is around the corner.
    I think it is safe to say that as it relates to avian flu, 
though none of us know the eventual effects, we certainly know 
the threat is great enough that we have reexamined our 
capabilities and one glaring deficiency was that we were 
unprepared or ill prepared to produce countermeasures to offset 
the degree of the threat. I believe we have sufficiently, for 
the short-term, addressed the needs, but only the needs for 
that one threat.
    My hope is, as we reauthorize this piece of legislation, 
that we will let our imaginations be a little more creative, 
that we will look across the scope of the world that is 
affected regardless of the artificial boundaries of agencies, 
and that at the end of the day, all will agree that as we move 
the deck chairs, that we are moving them so that the overall 
response capabilities are, in fact, better. So, I guess we are 
here today to discuss in more detail which chairs move and 
where those chairs move and what our capacity is and what our 
capacity should be.
    Dr. Agwunobi, a proposal being discussed which was also 
included in the White House's report on the response to 
Hurricane Katrina is the direct command and control of NDMS and 
all Federal medical response elements to HHS. If this is done, 
what plans would HHS implement to assure rapid, flexible, and 
sustainable Federal medical response? I guess I should ask 
first, do you agree with the report from the White House and--
--
    Dr. Agwunobi. Sir, I believe a lot of hard work went into 
the development of that report. It was very insightful. It 
reached out to all of the participants in the response to 
Katrina. It was a very deliberative process, and sir, I do 
concur with its recommendations.
    I know for a fact that the agencies that would be 
responsible for following through on the NDMS part of those 
recommendations, DHS and NHHS, are currently in deliberation. 
We are working very closely with them as we discuss not only 
how best to potentially come through on that recommendation, 
but also to assure that in going through, we don't threaten 
NDMS's ability to deliver on its mission in upcoming hurricane 
seasons.
    So, I know that a lot of work is ongoing, as we speak, as 
to trying to figure out the minute details. Should we change 
the format when it is moved? If it is moved, how best would it 
be to--in terms of how can we protect its ability to deliver 
our services this year and in future years?
    Senator Burr. Well, as a member of the Senate that 
represents a State that has a coastline and that has an annual 
opportunity to not just prepare but to actually practice 
response, this year is very important to me. Having said that, 
you know exactly what our capabilities are because you came 
from a State that had an annual opportunity to not only 
prepare, but to practice it, as well, and I think both of our 
States rate extremely well from a standpoint of their ability 
to handle up to a given point.
    Dr. Agwunobi. North Carolina is one of the best, sir.
    Senator Burr. Do you envision that there is any gauge that 
we can use of the degree of disaster before there is an 
automatic default to the Federal Government to be in charge 
versus local, State, and then a Federal request?
    Dr. Agwunobi. Sir, I believe strongly, and this doesn't 
just relate to the fact that I am a part of a team that 
supports this philosophy with Secretary Leavitt and the 
President, it actually relates back to my experience at the 
State level. I believe strongly that our focus should always be 
on local preparedness and local response, especially if our 
notion is all-hazards, because each community has different 
sets of assets and each community is going to respond 
differently.
    So I believe that as we go about improving our system over 
time, we should always have a focus on local public health, 
local preparedness, local emergency response, local National 
Guard and others, and then build on that. In other words, in 
this constant effort to improve preparedness at the local 
level, we should then assess what the role of the Federal 
Government should be in filling in the gaps or in backing up 
the system. I agree completely that we should always be there 
as a safety net should that system fail, but I always believe, 
sir, that local is better than----
    Senator Burr. I agree with you totally. I would ask you 
this question: Is it true that not all public health entities 
mirror each other?
    Dr. Agwunobi. Sure.
    Senator Burr. The difficulty that we found is that a 
community can have a public health infrastructure that truly 
can address anything they are thrown, and 30 miles down the 
road can be a public health entity that has, by default or by 
choice, become the vaccination point for low-income children 
and that is the extent of what they provide. Can we 
legitimately go through this reauthorization without defining 
what the face of public health is going to look like in the 
future and set a goal that that face be replicated in every 
community that we feel a public health infrastructure should 
address?
    Dr. Agwunobi. Sir, you bring up an excellent point. If you 
have seen one local community, you have really only seen one. 
There are no two that have exactly the same characteristics. 
Over the last--since 2001, sir, Congress and the President, 
that partnership has invested, I think, upwards of almost $8 
billion through CDC and HRSA grants into preparedness at the 
local level and that probably doesn't include the dollars that 
have come through DHS. Those dollars are focused not only on 
strengthening the individual strengths of each public health or 
each emergency preparedness entity within a community, but I 
think a lot of it has gone toward trying to set certain 
standards across each community while allowing each community 
the ability to figure its own way in terms of how it gets to 
that standard based on its unique characteristics.
    So, although I would concur, sir, that we do need to have 
expectations of each community and each local government, I 
would wager that their citizens have high expectations, as 
well. But, I think we should always seek to find local 
solutions as opposed to trying to apply a single cookie cutter 
approach across each community.
    Senator Burr. I certainly understand your answer. I am not 
sure how there can be a national framework if, in fact, the 
capabilities community by community have the ability to differ 
to a great degree, and I think this is what this subcommittee 
is struggling with right now, that if we limit this to the 12 
targeted cities for chemical, biologic, radiological threats, 
that is one thing. But when you begin to try to model the 
country for an H5N1 threat without the consistency of knowing 
what capability exists community by community, it is impossible 
to put together a response--a Federal response that is in 
total.
    I know we are not going to find the solution out today, but 
I guess my follow-up would be, is HHS open to the discussion as 
to what the face of public health should look like in the 
future and committed to try to achieve whatever we collectively 
decide that should be?
    Dr. Agwunobi. Absolutely, sir. I can say that without 
hesitation, that I have heard the Secretary himself ask his 
team to reach out to partners across the community to do just 
that. What should the future look like? As we design a path to 
that future and make that available to each community so that 
they can begin figuring it out, how they are going to get 
there, our role absolutely should be to help define that 
future.
    Senator Burr. Regardless of the community in America, who 
do you perceive in that community is in charge of a natural, 
deliberative, or intentional disaster? I mean, who would we 
look to in a given community to be in charge?
    Dr. Agwunobi. Sir, I think a natural way to look at this 
is, who does the community look to when there is trouble, when 
there is an emergency, when there is a crisis, and all too 
often, my experience in Florida, and indeed now as I walk 
around the Nation, has been that they look to their elected 
leaders. They look to their Congressional representatives, 
their governors, their mayors. I think Rudy Giuliani, as he 
stood on that podium at 9/11, is an example of what communities 
expect----
    Senator Burr. I agree with you, but Mayor Giuliani was not 
the one that determined where the debris went. He wasn't the 
one that determined how many assets needed to come in to 
support what may have been casualties that needed medical care. 
He was the mouthpiece, and I think we all know if there were a 
national disaster, we would look to the President for that 
ability to communicate with the American people.
    I am more concerned with who we default to on the ground in 
charge. Who is the one that we see, regardless of the 
community, that is the traffic cop deciding where the surge 
capabilities are, which hospitals receive which patients? In 
the event that there were contamination, who maintains the 
protection of a contamination line without a decision to move 
people outside of it?
    Dr. Agwunobi. Sir, North Carolina has a wonderful example 
of this in Leah Devlin, a great public health official, a great 
officer, and she offers great leadership on issues related to 
health and medical emergencies. But because emergencies like 
Katrina can be so much bigger than just health and medical 
issues, there needs to be someone above that level who is 
coordinating all of the activities of the different functions 
underneath, and so typically that is the Homeland Security 
Director or the Emergency Preparedness Director--they are 
called different names in different communities, but they all 
serve a very common function. They help coordinate and, 
therefore, lead across the individual areas.
    If it is health and medical, I am pretty clear in my mind 
that it needs to be at the Federal level, the Secretary of the 
Department of Health and Human Services. If it is health and 
medical at the State level, I am pretty clear in my mind that 
it needs to be the State health officer or the Commissioner or 
Secretary of Health. And then, of course, if it is at the local 
level, typically, local communities have a designated health 
and medical, usually a county health department officer or 
director.
    Senator Burr. Just out of curiosity, today, do we have a 
point of contact in all the States? Do we know who they have 
designated to be that person?
    Dr. Agwunobi. Yes, sir. On the health and medical side, 
very clearly. I can only imagine the Department of Homeland 
Security, who aren't here today, also have designated or at 
least contacted people in each State.
    Senator Burr. In all likelihood, is that person the same 
regardless of which agency is looking at it?
    Dr. Agwunobi. Yes, I think it has been. There is pretty 
good consensus, I think, across the Nation as to who leads the 
health and medical response.
    Senator Burr. So, is it safe to say that our plan, Federal 
plan, identifies an individual within that State designated by 
the State, regardless of the title, and then assume that they 
have put together a plan for that State to respond to whatever?
    Dr. Agwunobi. Yes, sir.
    Senator Burr. If you had to guess today, how many States 
have that plan?
    Dr. Agwunobi. An emergency preparedness plan that addresses 
health and medical needs?
    Senator Burr. That could respond to an all-hazard threat.
    Dr. Agwunobi. In fact, I think one of the requirements of 
the cooperative agreement, the funding that Congress provided 
through CDC and HRSA, one of the requirements was that each 
State, in order to benefit from those funds, needed to show 
that they had a plan to expend those funds in an efficient 
manner and in a way that changes the public health and the 
preparedness of their State, and I think all of the States have 
actually shown that they have that ability.
    Senator Burr. Ms. Embrey, some believe that DOD and the 
capabilities it controls is the only Federal agency that 
possesses the ability to effectively and rapidly respond to 
medical events of national significance. Because of this, they 
feel that DOD should take the lead in response. What are your 
thoughts on how the DOD assets should be utilized, integrated 
into a domestic Federal medical response?
    Ms. Embrey. Well, DOD has the advantage of command and 
control over its particular assets. For that reason, we are 
perceived as having good coordination and the ability to 
execute the assets under our control. But we are organized and 
our assets are trained and equipped to function in our 
warfighting missions and our peacekeeping missions, and we, 
with the global war on terrorism, are engaged pretty heavily in 
those activities with those assets. So the structure that 
exists today in the medical community is focused on those 
requirements and there is very little additional assets that 
have been organized to provide domestic support.
    We do have a commitment to planning. We have public health 
emergency officers at all of our DOD installations whose job is 
to work with the public health infrastructure outside the gates 
to make sure we have an integrated response here at home. We 
have an immediate response policy that authorizes all of our 
installations and our assets of all types, even medical, to 
provide immediate assistance where lives or property are at 
stake for a short time until other assets can be brought to 
bear.
    DOD has strength in planning and exercising those plans, 
and I believe that our biggest contribution to the readiness 
for response in this country would be to participate with our 
partners in establishing those kinds of training and standards 
and planning that we know how to do very well and share that 
with our lead agency partners.
    Senator Burr. In fact, DOD participated in Determined 
Promise in 2004, which was--it sort of tested DOD's ability to 
assist civilian authorities in a coordinated response to 
simulated chemical, radiological, and explosive hazards. 
Clearly, that coordination was lacking as it related to 
Katrina. As a result of that, what specific plans does DOD have 
that would improve that integration when the time comes? I 
guess, what did you learn?
    Ms. Embrey. Oh, we learned a lot of things. We learned a 
lot of things in the broad context of the response, more than 
just health and medical. From a health and medical perspective, 
I think we were fairly well coordinated.
    I think the challenge is that for the Federal agencies 
represented here, the VA and the Department of Defense have 
physical assets and people around the country and it is 
important that, in addition to having a national framework to 
understand how we integrate with each other through the 
National Incident Management System and through the various 
other capabilities that we have set up to provide surge 
capacity to a locality, more importantly, though, is we have 
these places and people in communities and it is important that 
we look at ourselves as part of that community and to plan with 
that community and to plan with that public health 
infrastructure and to plan with that State on how these assets 
could be brought to bear immediately, not waiting for a much 
larger coordinated surge.
    I think the real focus here is that we need to engage our 
State, local, and corporate partners, and private industry, in 
creating a community by community awareness of what our 
vulnerabil-
ities are and quantifying them and looking at the community as 
the entirety of all of the assets in that community, whether 
they are the FBI or, you know, any part of the Federal 
community. If we are there, we should be part of the planning 
process and agree to preestablished arrangements for roles and 
responsibilities of how that community would respond and be 
prepared and to identify specific gaps in capability so that 
that community could work with nearby communities to fill those 
gaps initially and expanding there.
    My belief is, and I believe the Federal Government is 
working toward a regional response model, where communities 
form a region within a State, perhaps, and a region of States 
becomes a region of communities, and that region of States 
becomes a plan in and of itself that recognizes the core reason 
why we have communities. There is some economic basis for those 
communities. It is either an academic center or a corporate 
town or a major government center or a financial center or 
maybe a combination of all of those things.
    Military bases, again, are sometimes the reason for the 
existence of an entity. And so it is important for us to allow 
those communities to define what is important to them and to 
define and set out in a common framework what they are capable 
of doing based on their population at risk, and that would have 
to involve the corporate partners who have an economic 
incentive to keep that city or area functioning effectively.
    And once we have done that, with all of us working together 
even at the local level, then bringing those together into a 
framework for a national response, using the National Incident 
Management System, I think is the proper way to go, and DOD is 
fully prepared to participate in that way and to provide 
support when needed with whatever resources we have that isn't 
otherwise engaged in our DOD missions.
    Senator Burr. I am going to ask one more quick question and 
then I am going to allow Senator Hatch to make whatever 
comments and questions that he would like.
    From a standpoint of the constant use of the Guard relative 
to deployment, should any of us be worried that their assets 
have been depleted to a degree that any State should be alarmed 
on our own capabilities to respond to disasters?
    Ms. Embrey. It is a very good question, Senator. I used to 
work in Reserve Affairs in the Department of Defense for a 
number of years, so I feel particularly aware of the demand 
that we are now placing on the National Guard. The National 
Guard is somewhat schizophrenic, and I don't mean that in a 
negative way. But the National Guard is a State asset to the 
Governor and the legislature in each State has the authority to 
assign that Guard under the authority of the Governor to 
perform State missions. They may employ National Guardsmen in 
that capacity that are not federally recognized to perform 
those State missions underwritten by the State legislature and 
the funding that comes from the State.
    In addition, the National Guard has federally recognized 
State employees that perform military missions. The Department 
of Defense takes those federally recognized assets and assigns 
specific military missions for them. In the past, it had been 
less and less of a--it was primarily for combat operations and 
it was primarily for surge for long-term operations. We are in 
a global war on terrorism which is a long-term, but maybe not 
highly intense, but it is a long-term commitment, and the way 
in which we now use the National Guard is for short tours over 
a period of time, which is different than it used to be.
    So there is a conflict between what the Federal Government 
and the military uses the National Guard for and for its 
evolving State mission role under the control and command of 
the Governor and the adjutant general in the States, 
particularly since the adjutant general in many States is also 
the emergency response coordinator in many States. This puts a 
triple burden, if you will, or a double burden, at least, on 
the National Guard, and we are quite sensitive to that. There 
are some legislative changes that have occurred in the last 
couple of years that have put even more burden on the National 
Guard to perform domestic response missions underwritten by the 
Department of Defense in terms of emergency response. So that 
came following the anthrax attacks and the 9/11 attack.
    Senator Burr. I am going to defer to Senator Hatch now. I 
will come back to you, and my concern probably deals more with 
equipment that is being left in theater that might have been 
equipment that was assigned to the Guard, used by the Guard, 
multiuse because it would be used for a State response, it is 
used in the war on terror. Leaving it there, they don't have 
that asset. Does that hurt us at all? But I will come back to 
that.
    Senator Hatch.
    Senator Hatch. Thank you, Mr. Chairman. To all three of 
you, if you care to answer any of these, welcome. We are proud 
of you and very pleased to have you here today. We want to work 
as closely with you as we possibly can.
    In organizing a response to an emergency, many of the 
suggestions that we have heard today or will hear today have a 
top-down focus. Create a new HHS office and make HHS the 
responsible agency, etc., etc. These are important concerns, 
but most biohazards are likely to be regional or local and 
local groups, agencies, and leaders direct and carry out the 
initial efforts, as you have been pointing out. The interface 
between local efforts and the engagement of broader national 
assistance is a critical control point where things can go very 
well or they can go very much wrong. This was an issue with the 
Katrina hurricane and the flooding that occurred there.
    Now, who should be the regional or local decision maker to 
initiate a decision to engage broader assistance? That is 
question number one. How do we assure that all regions and 
localities understand the process of rules for asking for, 
approving, and receiving this support? And are there Federal or 
State regulations that would hinder this process? If you could 
answer those.
    Dr. Agwunobi. Thank you, sir. Sir, if I understand your 
question correctly, I think I will respond as follows, and that 
is that the National Response Plan, and indeed most State 
plans, contemplate the fact that local-elected officials for 
particular sovereign areas have a primary responsibility for 
organizing within their teams of experts whether that be 
emergency preparedness or public health, and embedded in that 
responsibility is, I think in most plans, a clear process and 
expectation that those individuals will call for help if they 
need some.
    I know that at the State level, every governor sees as a 
part of their responsibility not only the maintenance of their 
executive branch agencies, including emergency preparedness and 
public health and their ability to respond locally, but also 
this notion that they have to, on an ongoing basis, assess when 
they are overwhelmed and when they need help from the Federal 
Government.
    Now, I also concur that the Federal Government has a 
distinct role in situational awareness. We have to constantly 
be aware of what the strengths and weaknesses of any given 
State are, as perceived by perhaps our measurements through the 
cooperative agreements for HRSA and CDC. As we invest, we have 
to be sure that we know how States are doing with that 
investment. But I do think that we also have to maintain the 
ability to come to the assistance as soon as we sense that a 
State is overwhelmed. But I still think that it should be 
something that is called for by State and local communities as 
opposed to something that is pushed upon them.
    I am not sure if I understood your question correctly, sir. 
I hope I----
    Senator Hatch. You have covered part of it, that is for 
sure.
    Ms. Embrey, do you care to add anything to that?
    Ms. Embrey. Yes, sir. I think I will address the question 
relating to the last question you asked in terms of regulations 
and what suggestions that we might take to improve our ability 
to do this.
    I think one of our challenges in medical response is how we 
are organized nationally. The States have responsibility for 
public health and safety and they reserve the right for 
credentialing. They reserve the right for formulary. They 
reserve the right for how we declare the cause and management 
of deaths in the States.
    During disasters, if there is a Federal response, 
credentialing issues always become a problem, especially for 
volunteers surging into the State. What can be brought to bear 
based on the formulary in those States becomes an issue that 
gets routinely waived, but it would be better if we were doing 
something about it in advance.
    And third, by having the capability to identify and surge 
needed personnel, because each State retains its own authority 
on that and it is a source of funding for the States, 
especially in credentialing. I think we need to examine a 
national framework that recognizes the authority and 
responsibility of the State, perhaps through validation and 
fund collection, but still has a national credentialing 
capability. I believe that is very important for us to have an 
effective national capacity. It is important for the Department 
of Defense as we live everywhere. Our doctors move all the time 
and they are routinely engaging in different credentialing 
efforts as they move from State to State. We should have a 
national standard that we all agree to across the States, but 
still give the States the authority to validate that credential 
as they move from State to State.
    Dr. Agwunobi. If I could just add to that, over the last 
few years, Congress has actually been moving in that direction 
as they have helped HRSA, one of the agencies within the 
Department of Health and Human Services, as it tries to develop 
and disseminate standards, an emergency credentialing-type 
standard across the States by investing in States, allowing 
them to build credentialing systems at each State level.
    Now, this year in the President's budget, there is a 
request to try and link all of that activity together into a 
national portal where--national is probably not the best 
description, nationwide portal, a portal that States can use in 
one State to check on the verification of credentials of 
practitioners coming from another State rapidly because they 
have been pre-credentialed in this system. We call it ESAR-VHP, 
which is a number of letters that mean a very long phrase of 
words, but basically it is an emergency credential verification 
system that allows people ahead of time--and by the way, sir, 
that is the best way to have a standing army to surge up to 
health and medical needs is to have them register ahead of time 
so we can do the due diligence, credential them appropriately, 
and put them in a database that, in an emergency, is readily 
available to everyone.
    Senator Hatch. Dr. Deyton.
    Dr. Deyton. Senator Hatch, several answers to your 
questions. Certainly the Department of Veterans Affairs is an 
extraordinarily well-endowed system to respond to local needs 
or national needs and it is one of our four articulated 
missions.
    In terms of a national response, obviously, sir, you know 
that we back up the Department of Defense for whatever medical 
needs that they have in a time of declared emergency or 
disaster or war. We also are obligated to work with State and 
local communities in terms of responding to what their needs 
are, and we do that in the context of the National Response 
Plan. So we stand ready to do that whenever that is needed.
    I am very glad that we are focusing on this as local issues 
and local responses because that is where any action will be 
required. The VA, again, is very well positioned because we are 
in every community in the Nation. We have got doctors, nurses, 
pharmacists, and psychologists everywhere. They are fully 
engaged in taking care of veterans, but when there are 
disasters or emergencies, we do ongoing planning both 
nationally within the VA system as well as in communication 
with State and local health departments at the lead with those 
Federal agencies. We have named contacts with every State 
health department to work directly with the VA.
    Senator Hatch, I think another important concept that we 
are just beginning to explore is the idea of Federal facility-
based deployable emergency response teams, and that is we have 
Federal endowments around the Nation, largely VA but also DOD 
and Public Health Service endowments, with Federal employees 
who are health care workers--doctors, nurses, pharmacists, etc. 
The four departments, DOD, HHS, Homeland Security, and VA, are 
exploring together the concept of would it be feasible to have 
established teams of health care providers at facilities who 
are trained and ready to be deployed in response to an 
emergency, an all-hazards emergency, to help with the surge 
capacity kinds of issues.
    Ms. Embrey, myself, Dr. Knable, sitting behind the 
Assistant Secretary here, and Dr. Waters from Homeland Security 
are all leading this effort at exploring the feasibility of 
this, and I think that that is a very exciting potential to 
consider. Obviously, we are working on it and we are moving 
ahead with that concept.
    Dr. Agwunobi. If I could just add to that, it is an analogy 
of something Congress has investigated in the last few years, 
the Medical Reserve Corps, which are teams of private 
physicians and nurses and nurse practitioners in communities 
that have come together to form teams that could be deployed 
either locally or within the region, and so that would be an 
analogy, where we might do the same thing over in the Federal 
medical agencies and medical facilities.
    Senator Hatch. With that reserve corps, I think we have 
provided some language that protects the reserve corps from 
liability, haven't we, or should there be language?
    Dr. Agwunobi. I am not sure if we have specific language, 
but clearly, they are, for the purposes of deployment, they are 
part of a Federal deployment----
    Senator Hatch. These are volunteers----
    Dr. Agwunobi. These are volunteers, that is correct.
    Senator Hatch. These are doctors who are willing to give of 
their time and effort----
    Dr. Agwunobi. Yes, sir. Yes, sir.
    Senator Hatch. We have got to provide some means whereby 
they are protected from liability should----
    Dr. Agwunobi. We do need to remove every barrier we 
identify.
    Senator Hatch. That is something we need to work on.
    Senator Burr. Is it my understanding that when those teams 
are deployed, they are Federal--they are designated as Federal 
assets?
    Dr. Agwunobi. Yes, sir. That was my point, that if they are 
a part of our response to an event, they come under our Federal 
protections.
    Senator Hatch. Out in Utah, we have found that that has 
really helped us in rural Utah and other areas, not necessarily 
in disaster situations, but just in everyday life. So we are 
really excited. I am really excited about that, and that may be 
a way of helping to bring down health care costs, as well. But 
one of the problems that exists is that we are going to have to 
provide some means whereby these people who are volunteers, who 
are totally capable of serving, who are experts in their field 
and who are qualified, have some degree of protection from 
medical liability concerns. So it is something I think we have 
to worry about on this committee and I hope that both sides, 
Democrats and Republicans, will recognize the importance of 
that corps that may be very helpful.
    Dr. Agwunobi. Four-hundred-and-eight. I mean, the response 
to this has been dramatic. Four-hundred-and-eight Medical 
Reserve Corps have stood up in recent years in 49 States. I 
think only North Dakota at this point, and they continue to 
work on building theirs. So it has been dramatic. The 
volunteerism in the health and medical providers with the 
private sector across our Nation stimulated by Congress has 
been absolutely dramatic.
    Senator Hatch. Mr. Chairman, the reason I bring this up and 
the reason I get excited about it is because there are a lot of 
doctors who are going out of the profession just because of 
medical liability concerns and the high cost of malpractice 
insurance. But they are willing to give their time free of 
charge as volunteers in our respective communities and 
elsewhere. We are going to have to find some way of protecting 
them and the Government is going to have to, it seems to me, 
provide that. Over the long run, it would be a very efficient 
cost for us.
    Senator Burr. I think it is safe to say, Senator Hatch, 
that there were some glitches as it related specifically to the 
response of Katrina where there were some assets that were 
asked to leave, where there was a delay because of the lack of 
one agency or another being the one to assume the liability. I 
am hopeful that internally, those glitches have worked out so 
there is not a delay in the future and I feel fairly confident 
in those national assets.
    Senator Hatch. I am going to count on Senator Harkin and 
others to assist in resolving this difficulty, because the more 
we can get qualified doctors to volunteer in the local 
communities--this isn't just for biohazards purposes but to 
help people who otherwise would not have medical care, we are 
going to have to find some way of, since they can't afford 
medical liability insurance, we are going to have to find some 
way where the Government backs this up. Hopefully, it will be a 
wonderful combination that will help us provide medical care at 
a much lower cost than what we are currently doing.
    I have other questions, but I feel like I have taken enough 
time.
    Senator Burr. Senator Harkin.
    Senator Harkin. I agree with that. I want to pick up on 
what we have just been talking about since I came in. I 
apologize, Mr. Chairman, for being late. Someone interrupted my 
schedule. But in talking about this reserve corps and health 
corps, that is all right as far as it goes, but consider what 
would happen, and I want to focus on a broader theme, what 
happens if we get hit with pandemic flu? We have got to have a 
broader pool than what is in the reserve corps right now.
    I would just say, Orrin, that I introduced a bill last 
year, S. 2112, the Seasonal Flu and Pandemic Preparedness Act, 
and then what we did there, the idea was to set up a pre-
cleared, pre-trained volunteer force all over America, not just 
doctors or nurse practitioners but other people that--there are 
a lot of nurses in this country, by the way, who went to 
nursing school. They may have been a nurse for a while. They 
got married, raised families. They are in our small towns and 
communities all over America. I discovered this in my State of 
Iowa. They have some background. They could be a great 
volunteer force. But they need to be trained and prepared and, 
in terms of the liability protection, what I did in my bill, 
Orrin, is I just said, cover them just like a Federal employee.
    Senator Hatch. Torts claims.
    Senator Harkin. But it seems to me that, and Dr. Agwunobi, 
it is probably more in your bailiwick than anywhere, but again, 
thinking ahead about a disaster of the nature of pandemic flu, 
I mean, people can say, ``Well, it may not hit here'' and all 
that kind of stuff, but just about every health professional I 
talk to says, ``Look, and we have had NIH here, we have had CDC 
here, we have had everybody up here saying it is not a question 
of if. The only question is when.''
    Never in the history of mankind since we have been studying 
viruses have we known a virus not to mutate. They all do. 
Viruses tend to become virulent, HIV being one that we 
recognize as being very virulent. This pandemic flu also seems 
to be one that is very virulent, and if it starts going from 
human to human--we have one case that I know of where it went 
from human to human. The CDC has documented one case. It seems 
to me that if we are going to get ready for this, we have some, 
in that Health Reserve Corps you were talking about, we sort of 
have a template of how this could be done. It just needs to be 
bigger and broader.
    Now, again, I am thinking of DOD, I am thinking of our 
National Guard forces that are out there also that could also--
these are civilians that are out there that could also be 
utilized and trained or maybe people that served in the 
National Guard, maybe they are out now but they still want to 
contribute some way. Find these people. But establish a pool of 
trained, identified people who are--you were talking about 
credentialing. Somehow, we have got to get these national 
credentials that every State recognizes, and that is why you do 
it now. You start doing it now so that the States buy in, they 
do get credentialed, scope of practice, what can they do. That 
varies by State to State, also, what can they do. Liability, we 
talked about that. Workers' comp issues, all these other 
things.
    So again, in that, what I guess is called the Emergency 
System for the Advanced Registration of Volunteer Health 
Profess-
ionals----
    Dr. Agwunobi. ESAR-VHP, sorry about that, sir.
    [Laughter.]
    Senator Harkin. So we have got a system there that kind of 
gives us a way to go.
    Dr. Agwunobi. Yes, sir.
    Senator Harkin. But it is just not robust enough to cover 
something like this, and so again, I don't know if I have so 
much a question as just a discussion about how we might do 
this. I left the VA out, but obviously we have VA in every 
State, too, and we have got nurses there and we have got other 
health-type professionals that may not be doctors, but they can 
sure give it a shot, because my vision of this is that if 
pandemic flu ever hits, it is not going to be enough to have 
people go to doctors' offices to get shots. You are going to 
have to do it at Wal-Mart, you are going to have to do it at 
churches on Sunday, you are going to have to do it at 
synagogues on Friday night, you are going to have to do it all 
over the place--shopping malls, sports arenas where people 
come. You are going to have to have systems set up where people 
can get these free flu vaccinations, or anti-virals, if that is 
the case.
    And so how do we go about doing that now? How do we start 
setting up a preparedness system that gets these people 
trained, give them periodic refresher courses. Obviously, if 
people die or something like that, you have got to have them 
replaced. How many people would it take? I don't know that I 
have a number in my mind, how many it would take. I don't know 
the answer to that question. But can we take that template and 
make it bigger for something like pandemic flu? I guess that 
is----
    Dr. Agwunobi. Yes, we can, sir. Congress and yourself as 
one of the leaders have helped us design the path, as you 
state, things like this Emergency Advanced Credentialing System 
that we have in place, and in the President's budget this 
request to add to that a portal that links all of the State 
credentialing systems together and makes the information that 
is in each of those systems available to each of those States 
and to the Federal Government, this notion that the providers 
in Federal facilities through VA and, of course, in DOD and at 
the National Guard level be roped into this concept.
    In addition to that, sir, I wear a uniform very proudly of 
the U.S. Public Health Service Commissioned Corps. Each of us 
are officers trained to lead others into health and medical 
battle. The opportunity to link our commissioned corps and its 
current ongoing transformation--we are adding a few officers 
and a few competencies in terms of building teams--allows us to 
now become the officers that lead those larger medical reserve 
corps into the fray, so to speak. We have all the pieces. We 
need a little bit of time to continue building upon them. And 
with the ongoing support that is already being exhibited by 
Congress, I am pretty certain that we will incrementally begin 
to grow.
    As I stated, 408 of these Medical Reserve Corps have stood 
up around the Nation. Each community recognizes their value. I 
think it is true, sir, that we have started with physicians and 
nurses, but we should add to them nonphysician and medical 
providers and have them grow into a larger team.
    Senator Harkin. And you would admit that that is not enough 
to handle a pandemic flu.
    Dr. Agwunobi. Sir, in a pandemic, it is going to take an 
awful lot more than licensed physicians and nurses to provide 
the care that is needed.
    Senator Harkin. They can provide the core of it, the 
leadership, as I said, the template of it, but we need--we 
talked about this----
    Dr. Agwunobi. Extenders, yes.
    Senator Harkin. How do we start doing that? I mean, we 
can't keep waiting and waiting and waiting and waiting. I mean, 
we have to find these people, identify them, get them trained, 
get them credentialed, work with the States. I mean, this takes 
time.
    Dr. Agwunobi. As we travel the States, the pandemic summits 
that we have been holding in each of the States, we are 
actually quite comforted to find that many States have actually 
gotten way out in front of this and have begun to do just what 
you are suggesting, sir.
    Senator Burr. Let me drill a little bit deeper than what 
Senator Harkin has, and I am confident that each agency that is 
represented here has a model for pandemic. Have you modeled it 
with 40 percent of the individuals not able to fulfill the 
commitment that you have got them designed in your model? I 
think that it is a conservative estimate, at any given point 
over the affected period of the pandemic, that 40 percent of 
health care workers won't be able to come to work. It is 40 
percent of law enforcement. It is 40 percent of truck drivers. 
It is 40 percent of the military that is down, that can't 
respond. Is there worst-case modeling that is currently going 
on and do we have the capabilities to overcome that type of 
challenge?
    Dr. Agwunobi. I think it is important that we state that we 
don't know for certain in a pandemic. We do know that there is 
going to be a pandemic in the future. What we are not clear on 
is whether or not it is going to be a 1918-like pandemic or a 
1968-like pandemic, which had a lot less impact on our 
communities. But we are using, for what we call our planning 
assumptions, 40 percent--people staying home for 2 to 3 weeks 
at a rate of about 40 percent of the workforce, either because 
they are sick or they are scared or they are caring for a loved 
one at home.
    The truth of the matter is, that is the challenge and that 
is why we have been reaching out into every community, every 
local community and saying, ``Listen, the truth of the matter 
is''--and I quote almost my Secretary when I say this--``if you 
fail to respond and develop a plan and try to prepare at your 
own local level because you expect that the Federal Government 
will come in and rescue you, you probably don't fully 
understand the concept of a pandemic, which is that every 
community is facing this simultaneously, and it is not that we 
won't have the will or the money, it is that we really don't 
have the way to get to every community simultaneously across 
the Nation in a pandemic.''
    So we are using 40 percent, sir. It is a model, meaning 
that there isn't a lot of science behind that particular 
number, and there is some variation across entities as to 
whether they use 45 or 35, but I think, on average, most people 
are using 40 percent as their model.
    Senator Burr. I know I will get into it with the second 
panel, but we are a just-in-time society now. Our economy is 
driven on just-in-time inventory. Should we be concerned--do 
you need to----
    Senator Harkin. Just one other----
    Senator Burr. Go ahead.
    Senator Harkin. Again, listening to this, you are right 
about the pandemic. I mean, if it happens, you are going to 
have to rely upon people in those local areas to take charge. 
It is that whole idea of pre-training. How do you get them 
trained? How do you integrate training of these people into the 
planning of this?
    Dr. Agwunobi. Sir, we haven't focused enough on that in our 
funding, cooperative agreements, and technical guidance. We 
have offered what we can to States and we have relied on States 
and local communities to figure out what their needs are 
locally and, therefore, what their training needs are going to 
be going forward. And we might offer more advice and more 
direction as we move forward over time. I know the Department 
looks forward to seeking input anywhere we can find it, in that 
regard. But we are listening to communities as we speak, and 
where we find communities who have a special need for training 
or a particular profession or a particular group, we are 
providing it.
    Senator Burr. Where typically we have said in the case of a 
disaster, be prepared to have 3 days of water, 3 days of food, 
the supply chain will be there to accommodate you, do we have 
to change that as it relates to the pandemic? Can we believe 
that that supply chain is going to be there? Should we be 
concerned if hospitals haven't rethought the degree of 
inventory they had because of just-in-time inventory and 
potentially 40 percent of truck drivers are out? This 
potentially means that that resupply line is affected in a 
significant way and that DOD is even more important from the 
logistics standpoint than envisioned in the current modeling.
    Ms. Embrey. DOD is well aware that the infrastructure and 
our ability to sustain economic commerce during a pandemic is 
very important. The commander at NORTHCOM is considering that 
and does believe that there is a possibility that the 
Department may be asked to provide support to the Nation in 
various places to ensure that commodities get to where they 
need to be. But DOD would do that in the context of support 
with other Federal agencies like the Department of 
Transportation and others to ensure that we sustain our 
economic--our commerce.
    Another idea that we believe is very important is to engage 
our corporate partners in their own campaign to educate and 
have a coordinator for their communities on what to do in this 
kind of crisis, how to sustain their operations and their 
supply chain and their distribution system, because they are 
going to be affected in the same way. So they need to come up 
with their plans and their contingencies and have a point of 
contact for us to talk to when they feel like they are going to 
be running south on that.
    So, yes, I think it is very important that the Department, 
the Federal, State, and local and private sector all work 
together on contingency planning for a loss--a potential loss 
of our capability during this pandemic, and it is truly an 
environment, it is not an event. It will happen over time. Some 
parts of the country will be perfectly fine, perhaps. Other 
parts will not. So it will really depend on how we coordinate 
and have the ability--pre-established alerts to say, ``You 
know, we are running a little short here. We need assistance.'' 
And so doing the pre-planning, having that coordination well 
understood in advance is the most important piece, and DOD 
understands that we may be asked and we are preparing in 
several areas to make sure that we can provide that support if 
asked.
    Senator Burr. Dr. Deyton, you have highlighted the fact 
that VA has a presence everywhere around the country. Operating 
medical facilities. They also are geared toward what the 
private sector utilities--which is just-in-time inventory. You 
have got the largest prescription drug availability in the 
country. So I think day in and day out, VA is challenged on a 
logistics standpoint. Give us VA's insight and expertise and 
experience so far as it relates to the logistics challenge that 
we might be faced with.
    Dr. Deyton. First, the good news is that we are all 
thinking about pandemic flu as a great model, and so for that 
one, we already have gotten guidance out to our facilities to 
begin to think through what are going to be our needs for 
sustaining care for veterans and for helping communities in a 
situation of a pandemic influenza. And so, we have given them 
actually lists and recommendations about the kinds of supplies 
that they may want to have more of available.
    In addition, we are working through our National 
Acquisition Center, which, you are right, sir, is probably the 
largest single purchaser of health care equipment and drugs in 
the Nation, and we have our National Acquisition Center that is 
working with the various distributors and contractors on 
language that will deal with these kinds of emergencies to make 
sure that they are doing exactly what Ms. Embrey said, putting 
in place whatever kind of continuity of operations that they 
need for their own distribution and supply so that they can 
maintain the supply that we all need.
    Now, VA also purchases through its National Acquisition 
Center supplies for other Federal agencies in response to 
disasters and emergencies, so that is why we take that very 
seriously and we are talking to our various distributors 
through the National Acquisition Center on what they need to do 
to keep the supply flowing.
    Senator Burr. I desperately need to move to this second 
panel so that we are not going to run out of time, but I do 
want to ask one last question of you, if I may. The VA, in 
briefings with us, have estimated that were there the need, 
they could free up 4,500 beds within VA facilities to meet a 
surge capacity, and I would only ask you, have you attempted to 
practice that, to know whether this is something that we can 
actually accomplish or that it is just a goal that we have set.
    Dr. Deyton. We do that all the time, because that is the 
support we give to the Department of Defense, and we on a 
regular basis do, in fact, assess the beds that we have 
available and how we would be able to staff them up, how we 
would discharge patients to free up those beds. Have we 
actually physically done a disaster drill to do that? No, sir, 
we haven't, but it is an annual--it is more frequent than 
annual, it is a regular counting thing that we do so that we 
can--we are obligated to make sure and get that information to 
DOD.
    Senator Burr. I lied. I am going to ask one last question, 
Doctor.
    [Laughter.]
    I don't want this to be associated with any of my 
colleagues up here. I will take the blame if, in fact, this is 
portrayed incorrectly. One could look at the worst case 
scenario for pandemic and say, ``if 40 percent of your health 
care providers are unable to perform their duties, a surge plan 
is sort of useless.'' Should we spend a tremendous amount of 
time as it relates to that surge capacity specifically as it 
relates to pandemic, or is that the reality, that if we have a 
1918 scenario, that we are more on the model that Senator 
Harkin mentioned and that every available outlet that we have 
got, we are trying to tap into, but the realities are that even 
if we had the 4,500 beds, if you haven't got the health care 
professionals to show up, that we have done no additional good 
other than move somebody from a bed at home to a bed at a 
facility?
    Dr. Agwunobi. Sir, you hit on a very important point here. 
In a pandemic, I think it is pretty clear that there are going 
to be a number of different things that we have to do as a 
Federal Government and as a Nation. One, we have to protect 
critical infrastructure, critical health care infrastructure. 
If there is only one producer of insulin in the Nation, a 
particular kind of insulin, we need to protect that 
manufacturer. If you are a vaccine producer, we need to protect 
your employees and your ability to develop vaccine. If you are 
the only specialist of your kind and you offer a particular 
kind of life-saving intervention, we need to find ways to 
protect you and your team.
    But I do think that when all is said and done, like in 
1918, we are going to have to adapt to many of those standards 
and many of those customs and norms that we apply in our health 
care setting today. We are going to have to adapt to this 
massive increase in demand.
    I do want to just state, if I may, the obvious, which is 
that although 40 percent of our folks will be out sick, 
fortunately, not 40 percent of our Nation will be in hospitals 
seeking health care. We expect that gradually, over time, there 
will be a surge-up in demand, and clearly, our approach is 
going to be how we manage that demand for services over time. 
So skills such as using anti-virals to shorten the length of 
stay will be a critical skill. Social distancing to 
particularly protect health care providers, I think, will be 
important. And then when the availability of the vaccine 
becomes ready, that they be a priority group in terms of 
protecting them for the rest of the pandemic.
    Senator Burr. One last question. After Katrina, health care 
providers provided aid through several distinct government 
agencies and programs. The responders on the ground worked hard 
to help Americans trapped on the Gulf Coast. But we have heard 
the stories of people that didn't get help for days or weeks. 
Were the medical treatment and patient evacuation problems 
caused by a lack of trained personnel, a breakdown of 
communications, inappropriate structure to the Federal 
response, or something else?
    Ms. Embrey. Yes.
    [Laughter.]
    Senator Burr. Is that all of the above?
    Ms. Embrey. I think Katrina was a conflagration of many, 
many different things. Geographically, it was quite widespread. 
It shut down what connectivity did exist between authorities to 
render a response. And many of the folks who were available to 
provide support had lost their homes or their families had been 
evacuated. And so I believe that the situation of the pandemic 
is different. Homes will be intact. Electronic systems and 
coordination systems will be intact. We will have individuals 
who will be sick, but if we plan properly and we set those 
connections and coordination points in advance, we will have 
the ability, particularly through surveillance.
    I think surveillance is another big area where we have a 
responsibility to come to some common agreement on how we 
communicate with each other across the States. Surveillance is 
not a standard in this country. It is an imperative and we all 
do it, but we all do it differently. It may be time to come to 
a common denominator on what is surveillance, how do we 
identify it across the Nation, how do we report and alert who, 
when, and that is another big area of opportunity here. I think 
we are working very hard to make sure that, right now, the 
differences become less so in our preparation.
    Senator Burr. We had some very good insight from the 
panelists that we had 2 weeks ago as it related to surveillance 
and some of it highlighted current directions and some of it 
suggested that we needed to rethink it, and I think it was 
beneficial to all of us.
    I want to thank all of you for coming. As one who 
represents a State where a mobile hospital was delayed for a 
few days from being deployed in Katrina because we hadn't quite 
figured out who was going to assume the liability, it is my 
hope that we won't have that problem again. From a conversation 
I had with a soon-to-be-former Governor yesterday who deployed 
medical assets, medical teams to Louisiana only for those 
medical teams to sit in Louisiana and not be able to perform 
their duties because the credentialing was not done at probably 
the most crucial time where lives could have been affected, it 
is disturbing to see the outpouring that existed within the 
country and the way people responded only to look back and find 
that we have a tremendous amount of work to do before we are 
able to sufficiently address something of that magnitude again 
and to look back on it and highlight the successes. But I am 
convinced that we are well on the road to doing that.
    At this time, I will dismiss the first panel and call up 
the second panel.
    Let me welcome the second panel, and my apologies because 
we did run over just slightly with the first one. My hope is 
that we will be able to conclude on time for the purposes of 
your schedule.
    Let me welcome Dr. Tom Inglesby, who is the Chief Operating 
Officer and Deputy Director of the Center for BioSecurity at 
UPMC. Previously, he was a member of the Johns Hopkins School 
of Medicine faculty and one of the founding members of the 
Center. Doctor, welcome.
    Richard Serino is the Chief of the Boston EMS Department. 
Mr. Serino also serves as the bureau chief for the city of 
Boston's Health Commission, where he assists in establishing 
public health goals and guides policy development. Richard, 
welcome. I also understand that you were intricately involved 
in the planning leading up to the Democratic National 
Convention, which I think can provide us a tremendous amount of 
insight in that planning and preparation.
    Dr. Eddy Bresnitz is the Deputy Commissioner of the New 
Jersey Department of Health and Senior Services. He is also the 
Secretary of the Council of State and Territorial 
Epidemiologists, who he represents here today.
    Dr. Rob Gougelet is an assistant professor of emergency 
medicine at Dartmouth Medical School and the Medical Director 
for Emergency Response at Dartmouth-Hitchcock Medical Center. 
His current duties also include the directorship for the New 
England Center for Emergency Preparedness and Medical Director 
for Emergency Response for the Vermont Department of Health. 
Welcome, Doctor.
    I am going to go in the order of introduction and you are 
open for whatever opening statement you would like to make and 
then we will move to questions.

STATEMENTS OF THOMAS V. INGLESBY, M.D., CHIEF OPERATING OFFICER 
  AND DEPUTY DIRECTOR, CENTER FOR BIOSECURITY, UNIVERSITY OF 
PITTSBURGH MEDICAL CENTER; RICHARD SERINO, CHIEF OF DEPARTMENT, 
  BOSTON EMERGENCY MEDICAL SERVICES; EDDY A. BRESNITZ, M.D., 
  DEPUTY COMMISSIONER AND STATE EPIDEMIOLOGIST, PUBLIC HEALTH 
  SERVICES BRANCH, NEW JERSEY DEPARTMENT OF HEALTH AND SENIOR 
  SERVICES, ON BEHALF OF THE COUNCIL OF STATE AND TERRITORIAL 
EPIDEMIOLOGISTS; AND ROB GOUGELET, M.D., DIRECTOR OF EMERGENCY 
        PREPAREDNESS, DARTMOUTH-HITCHCOCK MEDICAL CENTER

    Dr. Inglesby. Senator Burr, thank you for the opportunity 
to address you and the committee on this very important issue. 
I think your committee is to be commended for taking this on so 
directly.
    I have written comments, which I will submit for the 
record, but let me just pour out a couple of comments, 
especially after listening to the first panel.
    I think one of the things that needs to be clear is the 
central role of hospitals in an all-hazards medical response. I 
think that one of the things that sometimes gets glossed over 
is that a medical response is essentially, by definition, going 
to be centrally located in hospitals. That is where people get 
health care in America and I think that point is worth 
punching. Hospitals have largely been out of the hot water loop 
in terms of homeland security and emergency preparedness, 
public health preparedness. I know the committee is addressing 
that and I commend you for that.
    The second point is that I think in the event of a large-
scale catastrophe, even America's strongest and largest 
hospitals are at great risk of becoming dysfunctional quite 
quickly or perhaps even going offline and not being able to 
provide medical care. I think this is a serious risk which I, 
again, think you are taking on directly.
    I think that there are a number of things the first panel 
brought out in terms of the country's commitment to 
volunteerism, in some cases, nascent or just developing 
programs in HHS are going to be important, but overall, I think 
a general theme is that in terms of preparing America's 
hospitals to get ready for a pandemic or bioterrorist attack or 
large-scale chemical attacks, we are generally at the wrong 
order of magnitude and we don't have enough people in 
government and out of government working on this problem. I 
think the committee is considering a number of remedies for 
that and I look forward to talking about that.
    But I think those are the points that I would just bring to 
your attention at the start.
    Senator Burr. Thank you very much.
    [The prepared statement of Dr. Inglesby follows:]
             Prepared Statement of Thomas V. Inglesby, M.D.
                              introduction
    Ensuring the capacity to provide medical care to mass numbers of 
sick Americans in the aftermath of a major regional or national 
catastrophe should be a top national security priority. The Public 
Health Security and Bioterrorism Preparedness Response Act of 2002 
helped the country take a number of important initial steps toward that 
goal. But planning for a medical response to mass casualties remains 
the most neglected component of public health preparedness and homeland 
security.
    If an All-Hazards Medical response for hospitals is to be a major 
new initiative, there should be clearly articulated top hazards, and 
these must include pandemics and bioterrorist attacks. Of the kinds of 
catastrophes that could lead to mass numbers of ill persons, pandemic 
influenza and large-scale bioterrorist attacks would pose particularly 
severe problems given the prolonged duration of the crisis, the 
possibility for widespread geographic impact (even national impact in 
the event of pandemic), the fear of contagion to health care workers 
and their families, and the sudden demands on critical medical and 
material resources. Not all hazards should be of equal priority.
    A sense of the impact of a catastrophe on the scale of a 1918-like 
pandemic on U.S. hospitals can be gained using CDC's FluSurge program. 
In a typical city in a pandemic of moderate duration, flu patients, at 
epidemic peak, would be predicted to require 191 percent of non-ICU 
beds, 461 percent of all of the available ICU beds, and 198 percent of 
all available ventilators. Hospitals are in no condition to deal with 
this level of catastrophe: 30 percent of U.S. hospitals are currently 
losing money; of those that are profitable, operating margins average 
1.9 percent; 45 million Americans are uninsured, and hospitals provide 
$25 billion per year in uncompensated care. There are shortages of 
healthcare workers of all kinds. The numbers of hospitals and Emergency 
Departments have all decreased in recent years despite nearly half of 
Emergency Departments being over capacity.
    The following comments address questions of the subcommittee 
regarding the Federal Government's efforts to ensure the country can 
provide medical care for mass casualties:

     How should the recruiting, credentialing, training of 
Federal health providers be accomplished and organized? How should the 
Federal Government deploy health care providers in response to a 
national emergency?
     What is the most effective way to support a Federal 
medical response and which agency should take the lead?
     What steps should be taken to foster a more coordinated 
response built on a strong public-private partnership?
            increasing the health care volunteer work force
Recommendations
    (1) Create an Office of Citizen Engagement within HHS, presumably 
within OPHEP. A clearly designated office should have responsibility 
for the training, credentialing, liability, funding efforts of the 
Federal Government intended to increase the health care workforce in 
crisis.

     As top priority, the office should focus on developing 
local/state-based systems for recruiting, training, organizing 
volunteers to work in their own localities and States. Local volunteers 
would have pre-existing knowledge and commitment to their own 
communities, would not need to be transported to another region, would 
not need to be housed, etc.
     The office should also be responsible for the systems that 
would allow more efficient sharing, credentialing, movement of 
volunteers from region to region, given that some kinds of catastrophes 
could not be handled without influx of volunteers from outside the 
region.
     Will need plans to organize lay volunteers, not just 
health care professionals, to help hospitals provide mass medical care. 
Many of the things needed to run hospitals could be executed by lay 
professionals.

    (2) Increase funding and accelerate development of the state-based 
Emergency System for Advanced Registration of Volunteer Health 
Professionals (ESAR-VHP); ESAR-VHP is intended to allow States to 
better utilize their own health care resources. The program should be 
expanded and accelerated. Clear public description and discussion of 
ESAR-VHP and other community volunteer programs (both health care 
worker and lay volunteer) should take place in advance of a crisis. 
Many healthcare workers do not yet see themselves as being a crucial 
part of public health or community response, but would likely be 
willing to engage if the means of participation were clearer. Some 
health care professionals have wondered whether signing on to ESAR-VHP 
would mean they could be involuntarily drafted in a health emergency--
these kinds of misconceptions should be publicly addressed. One 
specific serious improvement would be for ESAR-VHP to induce States to 
use uniform credentialing guidelines across the country and to use 
databases that are compatible with each other to allow easier movement 
of volunteers across State lines should that be necessary.
    (3) Consolidate ESAR-VHP efforts and the Medical Reserve Corp (MRC) 
(whether or not this occurs in the new office of Citizen Engagement); 
Clarify role of MRC teams. Currently HRSA has responsibility for ESAR-
VHP, while the Medical Reserve Corp program office in the Surgeon 
General's office has responsibility for the MRC but no budget to fund 
the MRC units and offers no provision of liability protection for 
volunteers. These efforts should be consolidated. If MRC teams are 
meant to provide local augmentation of the health care workforce, then 
they should be explicitly training with hospitals where they work. If 
MRC teams are meant to provide a source of health care volunteers to 
other regions of the country, the MRC program needs a concept of 
operations, credentialing and liability process, administrative 
systems, processes, etc. to organize such movement of volunteers, and 
it should be clarified how the MRC will relate to the NDMS (see below).
    (4) Make liability protection in emergencies clear and national in 
scope. If health care workers volunteer to work in a mass casualty 
catastrophe, they are potentially putting their own lives at some risk 
(and their families if the crisis involves a contagious disease). They 
should not also be exposed to the potential of being sued. The Federal 
Government should pass some form of Good Samaritan legislation that 
protects health care volunteers working with a State or federally 
sanctioned volunteer program--with the exception being gross 
negligence. Absent this kind of liability protection, many potential 
volunteers will be dissuaded from participating.
         improving organization of the federal medical response
Recommendations
    (1) HHS should be the Federal agency responsible for the Federal 
Medical Response to large-scale catastrophes. There is significant 
confusion in the hospital and medical communities around the country 
regarding which agencies and programs are responsible for hospital 
preparedness. In the 2002 bill, the ASHPEP was given responsibility for 
this work, but he has not had the human resources or budget to 
accomplish the wide range of work necessary to prepare hospitals for 
the range of terror attacks, pandemics and catastrophes the Nation 
could face. Organizationally, matters were subsequently made worse when 
NDMS and the DMATS program were transferred to DHS. To fix this,

     HHS should be given unequivocal responsibility and 
accountability for all Federal medical response programs.
     Within HHS, the hospital preparedness program should be 
elevated in importance, visibility and resources, and it should be made 
quite clear who is the lead Federal official responsible for working 
with America's hospitals on hospital preparedness.

    (2) HHS hosp prep programs (and preparedness programs overall) 
would benefit from a stronger management structure and more senior 
managers. HHS should be given an Undersecretary for Preparedness that 
would be responsible for coordinating the large number of preparedness 
programs residing in HHS within OPHEP, HRSA, AHRQ, CDC, ONCHIT, NIH, 
FDA, et al. (It would be logical to include perhaps two or three other 
Undersecretaries responsible for the other HHS portfolios.)

     An Undersecretary for Preparedness would raise profile, 
importance of all HHS public health preparedness programs--including 
medical surge; should also improve coordination of these various public 
health preparedness programs--most of which do not now report to the 
ASHPEP.
     Creating the Undersecretary for Preparedness might be best 
accomplished by elevating the ASPHEP or by combining the Surgeon 
General's position with the new Undersecretary.
     Whether or not an Undersecretary for Preparedness is 
created, HHS will need to substantially augment its senior management 
cadre with persons with extensive experience and contacts with the 
private health care system.

    (3) The National Disaster Medical Response System needs strategic 
re-consideration. NDMS is in the Emergency Preparedness Directorate in 
DHS. Its mission is to support Federal agencies in coordination and 
management of the Federal medical response, to train voluntary disaster 
medical assistance teams from various parts of the country to ``provide 
care under any conditions at a disaster site'' and transport victims 
into participating definitive care facilities. A report written by 
senior advisor to the Secretary of DHS said that as of January 2005, 
the staff had been reduced from 144 to 57; there were few qualified 
medical personnel to develop doctrine or policies, and the agency 
lacked defined, unified medical capabilities.
    If NDMS is going to continue to exist, or if its work is 
consolidated or moved to another HHS program, then its mission, 
structure, and resources will need to be re-baselined:

     It needs to be in HHS and integrated with other HHS 
programs on hosp and public health preparedness.
     It should have as a top mission the support of hospital 
operations in communities in the midst of a crisis--this is not 
currently the case. DMAT teams have utility in certain kinds of crises, 
but would do little or nothing in the face of large scale crisis when 
hospitals will have major roles to play. In setting whether there are 
major medical surge needs, doctors and nurses will be necessary but 
insufficient--patients will need a variety of common medications, 
ventilators, oxygen, food, beds, IV fluids; doctors and nurses may need 
personal protective equipment, security, etc. These cannot be provided 
by teams. The only realistic or sustainable way to deliver this complex 
set of needs is in hospitals.
     NDMS plans should be integrated with the HRSA program that 
now allocates hospital preparedness funds. They are now in 2 different 
agencies, entirely distinct efforts.
     NDMS should be coordinate with the ESAR-VHP and MRC 
programs--which are all now completely distinct.

      strengthening the public-private partnership with hospitals
Recommendations
    (1) Congressional and Administration leaders should call America's 
hospital leaders to action. Hospital leaders would be more convinced of 
the long-term commitment of the Federal Government to hospital 
preparedness and more clear on what was being asked of them if they 
were gathered directly by national leaders and asked to commit to a 
long-term partnership to prepare the country to deal with mass casualty 
attacks. Hospital leaders now see very little Federal Government 
engagement on this issue except for a grant program that grants money 
that is far too little to accomplish what is called for.
    (2) HHS needs to set more clear benchmarks for hospital 
preparedness and pandemic funding. The 2004-2005 guidance for hospital 
preparedness grant awardees is 49 pages long. HRSA is developing 
guidance for this fiscal year, and it will be important to simplify the 
guidance, eliminate some of the indicators, sets more clear priorities 
in this next round. But the guidance is in the right ballpark--it's 
just that the funding that accompanies it would realistically pay for a 
tiny fraction of the work requested. The pandemic planning guidance 
recently issued by HHS for hospitals is reasonable, for the most part, 
but it needs more specificity, a clearer sense of top priorities, and a 
funding plan to meet the costs.
    (3) Increase funding for hospital preparedness.

     The National Bioterrorism Hospital Preparedness Program 
(under HRSA) has provided funding to hospitals of approximately $500 
million per year nationally since 2002, and the fiscal year 2007 
request is $487 million. This comes to about $100,000 per year per 
hospital though in reality it is less because some of the money is used 
by local health departments. In December 2005, Congress appropriated 
$350 million for State and local public health departments for pandemic 
preparedness; however, none of this appropriation is specifically 
identified for hospitals.
     The Center for Biosecurity rough calculation of the 
minimum costs of realistic readiness for a severe (1918-like) pandemic 
indicates a need for at least $1 million for the average size hospital 
(164 beds). The component costs to achieve minimal preparedness 
include:

         Develop specific pandemic plan: $200,000
         Staff education/training: $160,000
         Stockpile minimal PPE: $400,000
         Stockpile basic supplies: $240,000
          Total: $1 million per hospital

     With approximately 5,000 general hospitals in the United 
States, the national cost for initial pandemic preparedness would be $5 
billion. There would be recurring annual costs to maintain 
preparedness, estimated to be approximately $200,000 per year per 
hospital. These figures exclude stockpiling antivirals, since there is 
a separate national plan to acquire these drugs. In addition, no moneys 
are included for purchases of expensive equipment such as mechanical 
ventilators, since it is not clear that extra ventilators would be 
useful if there were no trained personnel to operate them. A rough 
estimate of the cost to double the number of ventilators in the 
country, using safe but inexpensive equipment, is $1 billion.

    (4) Increase the priority of regional hospital coordination. Many 
key health care system preparedness and response actions will require 
regional coordination: regional resource allocation, patient 
redistribution, and use of alternative care sites all require 
collaboration among hospitals, and among hospitals and public health 
and emergency management agencies, both in planning and in response. PH 
Law of 2002 encouraged the development of regional coordination, but in 
2006 there are only a few good examples of even nascent regional 
organizations. The United States has a highly fragmented, private, and 
competitive hospital sector with inherent disincentives for 
collaboration.
    To qualify for hospital preparedness moneys, hospitals should be 
required to participate in Regional Hospital Coordinating groups. The 
essential functions of such groups would include:

     Standardizing planning and preparedness among the 
participating hospitals;
     Sharing of assets, staff, and patients among the hospitals 
during declared crises;
     Sharing situational awareness in disasters to elected 
officials and health leaders;
     Coordination of timing and means of surge processes (the 
expansion of patient capacity within individual hospitals while 
retaining near-normal practice standards) and supersurge processes (the 
further expansion of patient capacity involving use of alternative 
sites and/or significant alteration in practice standards);
     Facilitation of a communitywide approach to ethical and 
political challenges (e.g., altered standards of care);

    (5) Modify the Stafford Act to allow for direct reimbursement of 
hospitals for uncompensated costs and extraordinary hospital care in 
the event of major catastrophes.

     Hospitals' revenues will decrease dramatically during a 
pandemic or in other catastrophes, even though they will be 
experiencing record-high patient volumes. Hospitals will need to 
provide care to many patients who are uninsured and/or unable to pay; 
at the same time operating costs will be extraordinarily high. 
According to the AHA, the average hospital has only 41 days of cash on 
hand. Many hospitals would have insufficient cash reserves to survive a 
severe pandemic or other crisis that significantly interrupts 
operations for weeks.
     Under current healthcare reimbursement schemes, hospitals 
lose money on nearly every illness-related hospital admission--
especially those, like pneumonia, that are likely to result from flu. 
Normally, hospitals offset these losses with profitable elective 
procedures, but these elective cases will be among the first services 
to be canceled or deferred in an attempt to respond to the demands of 
flu patient care during an epidemic.
                                 ______
                                 
                      Summary of Written Comments
    Ensuring the capacity to provide medical care to mass numbers of 
sick Americans in the aftermath of a major regional or national 
catastrophe should be a top national security priority. The Public 
Health Security and Bioterrorism Preparedness Response Act of 2002 
helped the country take a number of important initial steps toward that 
goal. But planning for a medical response to mass casualties remains 
the most neglected component of public health preparedness and homeland 
security.
                  recommendations to the subcommittee
Increasing the Health Care Volunteer Work Force
    (1) Create an Office of Citizen Engagement within HHS, presumably 
within OPHEP.
    (2) Increase funding and accelerate development of the state-based 
Emergency System for Advanced Registration of Volunteer Health 
Professionals (ESAR-VHP).
    (3) Consolidate ESAR-VHP efforts and the Medical Reserve Corp (MRC) 
(whether or not this occurs in new office of Citizen Engagement); 
Clarify role of MRC teams.
    (4) Make liability protection in emergencies clear and national in 
scope.
Improving Organization of the Federal Medical Response
    (1) HHS should be the Federal agency responsible for the Federal 
Medical Response.
    (2) HHS hosp prep programs would benefit from a stronger management 
structure.
    (3) The National Disaster Medical Response System needs strategic 
re-consideration.
Strengthening the Public-Private Partnership With Hospitals
    (1) Congressional and Administration leaders should call hospital 
leaders to action.
    (2) HHS needs to set more clear benchmarks for hospital 
preparedness.
    (3) Increase funding for hospital preparedness.
    (4) Increase the priority on regional hospital coordination.
    (5) Modify the Stafford Act to allow for direct reimbursement of 
hospitals for uncompensated costs and extraordinary hospital care in 
the event of major catastrophes.

    Mr. Serino. First off, thank you for allowing me to be here 
today, probably the one that is most out of his element. I am 
used to being in the street, and recently in the last few days 
with the crane collapses and being first on scene at multiple 
shootings and bus crashes. This is a little bit out of my 
element.
    Senator Burr. May I ask you to pull that microphone just a 
little bit closer? It is that Southern accent that I am having 
trouble with.
    Mr. Serino. Yes, I have a little bit of an accent, they 
tell me. I don't know, I think everybody else here does, but 
anyway, thank you for being here. I have a few remarks.
    One of the things I heard people say that I want to echo is 
there was a Congressman that had some influence up here a few 
years ago by the name of Tip O'Neill, and Tip said quite often 
that all politics is local. My expertise and experience has 
told me that, in fact, all disasters are local, as well, and I 
think that that is important to remember.
    Today, as you mentioned, I would like to focus on the 2004 
Democratic National Convention, where we had over 70 different 
local, State, and Federal agencies that took part in planning 
for an event and some of the lessons that we learned from that 
event. In 2003, it was designated a National Special Security 
Event, an NSSE, and that is an important fact because when we 
led to the creation of the executive steering committee and 17 
planning subcommittees, medical planning was not initially in 
the NSSE structure. There was nothing to look at, no medical 
component at all. As a result of local efforts, we established 
a medical subgroup as part of the consequence management 
committee and Boston EMS was designated as a lead for all 
medical consequence management planning.
    The medical subgroup was composed of 39 different partner 
organizations, Federal agencies, private sector, local 
hospitals. As a result of this highly successful partnership of 
local expertise with Federal assets and agencies--the formation 
of the medical subgroup--it established a role for the medical 
community on the executive committee and represents one of the 
major successes. The event is actually having a medical voice 
with the law enforcement agencies, which doesn't exist even now 
as we move forward.
    The primary task for the medical subgroup leading up to the 
DNC was to plan and prepare for major medical response issues. 
Our planning process addressed issues of surge capacity, 
hospital readiness, public health surveillance, requests for 
Federal assets, traffic impact--we don't have any traffic 
issues in Boston--and medical treatment of prisoners and 
protesters.
    As a result of the subgroup's work, over 200 ambulances 
were available. Using DHS grant funding, we provided actually 
mini-grants to mutual aid providers that had not been able to 
get any sort of assets at all for the purchase of medical and 
basic personal protective equipment. We completed additional 
training exercises with the hospitals. Surgeries were canceled 
within the city for the week. Also, throughout the week, we 
were able to maintain 500 free beds in the city of Boston, 
where in a normal week, we are lucky--almost every hospital in 
the city is on diversion with no beds.
    We also prepared for a specific threat of a bioterrorism 
attack using caches of chem packs, emergency response packs, 
stocking hospitals with nerve agent medications and radiation 
treatments. Finally, the city of Boston prepared to activate 
the local Metropolitan Medical Response System Agreement, which 
is a mutual aid system. We have a memorandum of understanding 
guaranteeing the availability of hospital staff and resources 
to assist in response to an emergency. We have an MOU with all 
the different hospitals so we can bring staff and move them 
around as necessary from the hospitals.
    The DNC proved to be a huge success in terms of emergency 
preparedness with few exceptions. The planning allowed for a 
successful blending of security and medical responding to 
threats during the DNC. Our success in medical planning came 
from bridging the gap between a well-integrated medical 
community and the public safety and Federal agency responsible 
for managing the event.
    Well before the DNC, we had a lot of experience working 
with the Conference of Boston Teaching Hospitals to manage 
disaster plans in the city. It came time to plan for a major 
event. There was already a local group, local officials and 
private organizations that we have been working hand-in-hand 
with for years. Bringing them into the NSSE structure, the 
medical community, law enforcement, and Federal agencies were 
able to meet each other personally and understand each other's 
personal and specific needs.
    As a result, planning for ambulances to access road 
closures, which turned out to be one of the major issues, as 
well as treatment of patients, deployment of resources were 
worked out in advance, and perhaps most importantly, the 
relationships developed and nurtured have carried forward 
today. Relationships are the key to developing them and 
fostering them is the greatest asset in a response. By 
establishing and carrying forward committees and organizations 
that addressed planning and response issues, the people who 
have to work together in a disaster already have to know each 
other.
    Many of the same groups that were brought together for the 
DNC continue to meet, coordinate on medical issues. 
Furthermore, by including the medical community in the planning 
process, other agencies have learned how important that 
planning is, law enforcement and the public safety agencies, 
and that was a seat for the medical community on the U.S. 
Attorney's Anti-Terrorism Advisory Council. The medical 
community is now an integral part of Boston's homeland security 
planning. Every day, the impact is felt in Boston. As we 
prepared to receive victims from Hurricane Katrina, the same 
planning and staffing agreements that were refined during the 
DNC allowed us to plan for an unknown number of medical cases.
    In less than 2 weeks, we will have the Boston Marathon 
coming to Marathon, the 125th, I believe--no, 110th running of 
the marathon, and we look at those incidents. We treat it as a 
mass casualty event and practice medical planning and volunteer 
integration, as we were talking about earlier. We look at these 
events as a special event as a planned disaster in order to try 
all these different assets out. As a result of this 
integration, in Boston, we are trading business cards at the 
scene of a disaster, and not something that should be 
happening.
    There is, however, much to be done. The lessons learned 
here must be brought to a national level. While medical issues 
are addressed in Boston, nothing in the guidance from the 
Department of Homeland Security addresses that the medical 
community needs to be included in everyday planning and 
coordination. While integration of the medical community in the 
NSSE structure in the DNC was a resounding success, the 
structure has not been formalized. These lessons must be 
learned nationally to address local planning and integration.
    Again, thank you for giving me the opportunity to speak and 
I look forward to answering questions.
    Senator Burr. Thank you very much.
    Doctor.
    Dr. Bresnitz. Senator, thank you and thank you for inviting 
me to come to participate in this roundtable today. There is 
some written comments. Just a couple of highlights.
    I want to say that we think that the guiding principles for 
reauthorization are some that have been already talked about 
earlier this morning. Certainly, an all-hazards approach is the 
way to go, but with the understanding that every--just like we 
talk about every event is local, every event is different. So, 
for example, dealing with influenza pandemic is different than 
dealing with an anthrax attack or plague or anything else or 
flooding.
    We must have predictable and sustained funding. I think 
that those of us in the States have experienced sort of the ups 
and downs of funding and they have impacted on how we went 
about our preparedness efforts and we are facing additional 
reductions in the coming year because of shifting of 
priorities.
    Workforce development, we have talked about the volunteers, 
but on the professional side, we need to really pay attention 
to that because the professionals, who are full-time, are the 
ones that are going to be assisting and guiding the volunteers.
    And finally, there is the issue of accountability with the 
use of performance measures, which I know the CDC and HRSA have 
done a lot of in the last few years and I think that has helped 
us in terms of our preparedness efforts.
    I have to emphasize, I know the focus today is sort of how 
the Federal Government can get better in preparing for an all-
hazards approach, but really, a Federal response for health 
care is really built on a solid foundation of State and local 
preparedness and I think people have highlighted that this 
morning.
    Secretary Leavitt has actually stressed in reference to a 
pandemic that the first response has to be local, and I can 
tell you that at the State level, we are not going to be 
waiting for the Federal Government to ride in on a white horse 
to save us because we don't think that is going to happen. I 
mean, every single community will be impacted. They may not be 
impacted exactly the same amount on any given day, but they 
certainly would be impacted over a few months' period and then 
perhaps in successive ways.
    New Jersey has had the--in terms of preparedness, it has 
had the good fortune, I don't know necessarily in terms of 
outcome, but we have had a real bioterrorism attack back in 
2001. We were the epicenter for the anthrax attack, although in 
DC., they may have thought they were the epicenter. The letters 
went through the Hamilton Post Office, and we did have a very 
significant local response. At that time, we had very little 
funds in the State for surveillance issues and for other 
response issues and we very much depended on the CDC and the 
epidemiologic SWAT team to come, if you will, to assist us, and 
they did assist us and it was mostly local response and I think 
overall, given that we had never experienced that before, we 
came through it very well despite not having lots of local 
resources.
    Last year, we had a staged event. We had the TOPOFF III 
exercise. I don't think it went as well, as we did during the 
anthrax attack in 2001, as a staged event. We had some 
decisions--the bottom line is the decision was made to 
basically prophylax the entire State within 24 hours. Well, 
there are not enough people within the State or even at the 
Federal level to do that, so the solution was basically to 
deploy Federal workers as well as postal workers to come in and 
hand out antibiotics in post offices. Unfortunately, that 
really wasn't a workable decision, and nevertheless, that was a 
decision that was made, and so we had--for a virtual reality 
problem, we had sort of a virtual unreality solution that 
didn't really work.
    One of the questions to us today is who should be the lead 
Federal agency. You asked that this morning. I don't think 
there is one lead Federal agency for all situations. I think 
for medical and public health events, it needs to be the 
Department of Health and Human Services. Similarly, at the 
local level or at the State level, it depends on the event. For 
something like influenza or a plague attack, it does have to be 
health. It is mainly a health issue, although clearly there are 
infrastructure implications, as well.
    For an explosion, for an example, it may not be a health--I 
mean, clearly, health is involved, but there are other issues 
related. Health can usually handle that, but shouldn't 
necessarily be in the lead at that time except certainly to 
care for the individuals.
    States have to take the lead on surge capacity issues. It 
is hospitals that provide the health care, but even in the 
pandemic, it depends on the pandemic because we don't know 
really how it is going to play out, but many people may be only 
mildly ill or moderately ill and not require a hospital. 
Hospitals will be overwhelmed. But we have to have other 
solutions to care for all those people.
    Clearly, any health response has to be a State and local-
based response. The Federal Government can only assist to a 
certain extent, but when you have a disaster all over the 
country, it can't just be a dependence on the Federal 
Government. It has got to be State and local.
    And finally, I just have to comment, there was a question--
I know today we are not talking about surveillance, but since 
the last panelist brought it up, I want to say that the States 
believe that surveillance is best done at the State and local 
level and not at the Federal level in terms of public health 
surveillance and epidemiologic surveillance for reportable 
diseases, whether they are intentional or natural in nature.
    With that, I thank you and will be happy to participate and 
answer any questions.
    Senator Burr. I appreciate your insight and will assure you 
we got an earful last week as it related to the surveillance 
issue, and I think that is an area that we have now flagged to 
sort of take a second, third, and fourth look at as we go 
through.
    [The prepared statement of Dr. Bresnitz follows:]
           Prepared Statement of Eddy A. Bresnitz, M.D., M.S.
    Mr. Chairman and members of the subcommittee, my name is Dr. Eddy 
Bresnitz, Deputy Commissioner for Public Health Services and State 
Epidemiologist in the New Jersey Department of Health and Senior 
Services, and Secretary-Treasurer of the Council of State and 
Territorial Epidemiologists (CSTE). Thank you for your invitation today 
to participate in a roundtable on All-Hazards Medical Preparedness and 
Response.
    The questions before us today are: How do we, (Federal, State and 
local agencies) appropriately prepare for and respond to events that 
require Federal healthcare resources, using effective financial and 
logistical support, based on evidence-based best practices? At the 
outset, we would like to echo the statements of Dr. Leah Devlin and 
others, representing the Association of State and Territorial Health 
Officials, made recently before the Senate HELP Committee. The key 
guiding principles for State and Federal preparedness outlined in their 
testimony included an all hazards integrated approach, predictable and 
sustainable funding, workforce development, implementation of 
performance measures, and accountability.
    It should be clear that an effective Federal response must be built 
on a solid foundation of State and local infrastructure consisting of 
well-trained public health (PH) personnel, state-of-the-art equipment, 
flexible healthcare surge capacity, comprehensive preparedness 
policies, plans and procedures, and sufficient operating funds to 
sustain capacities and capabilities. As Secretary Leavitt has stressed, 
a nationwide PH emergency, such as an influenza pandemic, could only be 
effectively addressed by comprehensive and sustained preparedness at 
the State and local levels as the Federal Government could not possibly 
provide direct healthcare support at the local level when the outbreak 
is occurring in every community. Predictable Federal funding is the 
key.
    Two events last year, one real and one staged, highlight the 
disorganization in the Federal response to provide healthcare personnel 
for healthcare and prophylaxis. In Louisiana, where the infrastructure 
had virtually disappeared, there were many impediments to effectively 
mobilize and support needed healthcare personnel from other States. In 
New Jersey during TOPOFF 3, the Federal solution to mobilize personnel 
to distribute antibiotic prophylaxis was developed through an ad hoc 
approach and was unrealistic but imposed on the State despite expressed 
reservations on its likely effectiveness. The MRC and ESAR-VHP systems 
for recruiting trained healthcare providers are relatively early in 
their development and require better coordination and sustained efforts 
on the part of all parties to enhance recruitment and address the 
cross-state credentialing and liability issues. And States must be 
equal partners in personnel deployment decisionmaking.
    Federal logistical support for local needs in a PH emergency must 
work through existing State and local command and control and emergency 
response infrastructure. The appropriate lead Federal agency should be 
determined by the event. For example, for biological PH emergencies 
such as an influenza pandemic or a plague attack, DHHS is the most 
appropriate agency to coordinate the medical and public health 
response. Similarly, State health departments have strong relationships 
with State Hospital Associations, in addition to their statutory 
regulatory oversight. The lead Federal agency must work through the 
State DOH, in conjunction with the State Hospital Association, to 
coordinate preparation and response to mass casualty events where 
Federal resources are required. In summary, the appropriate Federal 
healthcare response is one coordinated and led by existing State 
emergency response systems. Thank you.

    Senator Burr. Doctor.
    Dr. Gougelet. Good morning, Mr. Chairman, and thank you for 
the opportunity to testify before your committee today. I have 
presented written comments that are included in your packet of 
information. I will be very brief so we can get on to some 
questions, I believe, considering the time.
    I would like to discuss, just for a minute or two, that we 
are actually very concerned about surge capacity and widespread 
events overwhelming public health emergencies, surge capacity 
events. We have identified what I believe to be a significant 
gap in terms of the personnel needed for staffing for 
alternative care facilities and community-based health 
response, including immunization, prophylaxis, hospital bed 
surge capacity, isolation and quarantine.
    We believe and have worked through some of the details 
related to sub-state regionalization and interstate 
regionalization, which I believe are very useful tools to 
enhance the response and to coordinate and efficiently bring 
resources together. We have an example of that through the 
Interstate Regionalization Program. The Northern New England 
Metropolitan Medical Response System brings the resources of 
Maine, New Hampshire, and Vermont together in a planning 
mechanism and response capacity which we feel is very 
successful and brings three primarily rural States together to 
have capabilities that they might not have otherwise.
    In terms of the Federal Government's role in this, of 
course, they have multiple roles, but one of the most important 
roles I see the Federal Government to have is to provide 
concise planning and technical information to communities so 
that we can form within sub-state regions and within States' 
uniform capabilities, the framework that we need--the framework 
that we desperately need across the Nation that has 
similarities. There are differences between States and local 
communities, but there are common structures that I believe 
that we can incorporate into local communities so that there is 
a standardization, and maybe standardization isn't the right 
word, similarities between these structures from State to State 
so that staffing can move across borders, we can have common 
equipment and supplies, but more importantly, that we have a 
foundation for establishing performance standards that can 
reliably make up the Nation's response by adding all of these 
State and sub-state capabilities together.
    The question came up of logistical support for a massive 
Federal response, and I believe there is a role for the 
Department of Homeland Security to control large-scale 
logistical support in cooperation with the Department of 
Defense. I would emphasize--having been a DMAT member since the 
late 1980s--that if any changes occur through the Federal 
response system and NDMS, that particular care be taken to 
maintain the services that are currently available and to let 
the many thousands of volunteers that currently do this work 
know that they are not only valued in their services, but those 
services are going to continue and that the work that they do 
has significant merit. I feel that is a very important 
notification that we should give to that group.
    In addition to that, I think that at this point in time, 
with all of the potential shuffling around going on, that I 
would encourage both the Department of Homeland Security and 
the Department of Health and Human Services to look at each of 
their agencies' strengths and weaknesses and to bring those to 
bear to create a rapidly mobile and efficient response 
capability that can really be preserved in the coming months 
for the hurricane season and other threats coming up.
    And the last issue relates to the private health care 
delivery system. I think that there should be resources 
available for private sector facilities to participate in 
emergency response and planning as well as we should be aware 
that if penalties exist or loss of income exists, when private 
institutions help, that those should be discouraged at the 
Federal level and that in terms of involvement of private 
health care facilities, I think that the sub-state regions that 
we talk about in our documentation is a good way to get the 
private health care system into the planning table and to 
participate in the response capability of both the State and, 
therefore, the Nation.
    Thank you.
    Senator Burr. Thank you very much.
    [The prepared statement of Dr. Gougelet follows:]
                Prepared Statement of Rob Gougelet, M.D.
    The Nation's ability to respond to a mass casualty national 
emergency is the inherent capability of the Federal Government to 
respond and the composite of each State's ability to respond. They each 
present with their own limitations.
    The Federal Government has limited resources to respond to 
overwhelming and widespread natural events such as Hurricane Katrina or 
a Pandemic influenza event. Overwhelming and widespread terrorist 
events will further challenge the Nation's ability to respond, as there 
would be no advance warning, and there would be intentional attempts to 
injure as many civilians as possible including direct attacks on first 
responders, health care workers and medical facilities. Federal 
response to locally catastrophic events is limited by the time it takes 
for resources to arrive in a community. Many times death and injury 
occur during the event or within the first few hours of the incident, 
emphasizing the need for an appropriate local response. In these two 
cases, the Federal response should be to anticipate, plan for, provide 
guidance and technical support, communicate with, and efficiently 
respond to communities where these incidents occur.
    Individual States also have limited capacity to respond to 
overwhelming events. Each State should be broken down into sub-state 
regions that can provide critical response capabilities. Each State's 
capacity to respond to an overwhelming mass casualty event is then a 
composite of capabilities of sub-state regions. A Regional Response 
System (RRS) is sub-state region described as a metropolitan area, a 
sizable town and its surroundings, or multiple towns in a rural 
setting. An RRS is determined on its ability to plan for and provide 
critical services during the time of an overwhelming mass casualty 
public health emergency. Although all towns currently plan for and 
respond to a wide variety of emergencies, critical response 
capabilities necessary to respond to mass casualty events can only be 
provided by smaller towns or regions working together. Some examples 
include setting up community-based mass prophylaxis and immunization 
sites, community-based hospital surge capacity beds, or isolation and 
quarantine facilities. The Nation's capability to respond at this sub-
state level is where a critical gap exists between resources needed and 
resources available.
    Hurricane Katrina in particular demonstrated how a catastrophic 
emergency can overwhelm local response and leave a critical gap in 
response efforts until massive Federal help arrived days to weeks 
later. During this gap in effective response, death, and suffering 
continued in an environment of hopelessness and chaos. Analyses of 
potential biological terrorist attacks involving tens of thousands of 
casualties predict a similar gap in response capabilities.
    The timely and effective use of the vast, distributed regional 
response resources requires careful and practical planning among 
communities and States before the actual need arises. Once an incident 
occurs, it is too late to develop the relationships, policies, and 
procedures to figure out how to integrate and apply such diverse 
resources in a timely and effective manner.
    The concept of using regional response resources is predicated on 
comprehensive planning for use of local, State, and Federal resources 
from within a region. This planning along with appropriate and 
realistic exercises is needed before a catastrophic emergency. During 
such an emergency, the local medical and emergency first response 
resources would be the first line of defense. Any serious flaw in this 
first response would seriously jeopardize all of the following 
responses. The first responders must be able to quickly build the 
foundation by which outside resources are efficiently integrated and 
effectively utilized within the community. The use of regional 
resources is necessary because of their close proximity and they may 
possibly have sufficient numbers to effectively fill the gap between 
the local and State response and the subsequent Federal response.
    Regional planning both interstate and intrastate can be useful 
tools for closing the gap between local State and Federal response.
    The intrastate Regional Response System (RRS) can facilitate 
planning and response to catastrophic emergencies for all types of 
hazards. Man-made and natural disasters include a vast array of threats 
from fires, floods, hazardous materials releases, transportation 
accidents, earthquakes, hurricanes, tornadoes, pandemics as well as the 
terrorist arsenal of chemical, biological, radiological, nuclear, and 
high-yield explosive weapons. The development of Regional Response 
Systems (RRS), along with implementing actions in order to ready 
communities, States and, indeed, the entire Nation to respond 
effectively to all-hazards catastrophic emergencies will provide a long 
needed framework to incorporate local, State and Federal resources 
during the time of an emergency.
    If each State's sub-state region or regional response system (RRS) 
is tasked with critical capabilities such as setting up an alternative 
care center, then we begin to form the building blocks for a true and 
reproducible national response.
    Estimates or predications of casualties anticipated during 
different types of outbreaks, natural disasters or terrorist attacks 
are a necessary first step to determining the types, numbers, location 
and timing of responders necessary to deal with varying mass casualty 
events. The next step would be to determine the medical care necessary, 
and the resources needed to give that care.
    For example, if hospital bed surge capacity is the response 
required, the first step is to define the role and limitations of 
hospitals during the event. Hospitals are the only resource other than 
field treatment that have immediate or near immediate health care 
capabilities. During a Pandemic event, it is anticipated that hospitals 
will be filled to capacity with seriously ill patients and also 
severely limited in their response capability by staff (and their 
families) illness and death. Hospitals will also be compromised by the 
loss of critical medical supplies and pharmaceuticals, and possibly 
even power and communications failures.
    Community-based facilities extend the State's surge capacity beyond 
acute care hospitals. These facilities allow definitive health care for 
patients during mass casualty incidents that exceed hospital surge 
capacity. They also provide an alternative site for treatment should a 
hospital be evacuated or incapacitated. There are two different types 
of community-based facilities: alternative care facilities (ACF) and 
acute care centers (ACC).
    Alternative care facilities are community-based medical facilities 
usually used for outpatient treatment that during the time of a mass 
casualty event, can be readily converted to care for patients needing 
hospitalization. An example of an ACF would be a nursing home or 
ambulatory surgery center.
    Acute care centers are located buildings of opportunity. These are 
community facilities that simply provide space. Examples include 
armories, auditoriums, conference centers, and gymnasiums. The ability 
to provide treatment is dependent on all medical supplies and staffing 
being brought to the site. This type of facility would also be the 
receiving facility for outside Federal resources such as the Federal 
Medical Contingency Station.
    Using this scenario, local Medical Corps personnel can plan for and 
staff an alternative care facility. NDMS, and commissioned corps 
personnel can later provide backfill upon arrival.
    A large gap exists in trained health care workers to staff 
community-based health care facilities including alternative care 
centers, immunization and prophylaxis clinics and isolation and 
quarantine facilities.
    To successfully recruit, train, exercise and sustain health care 
providers is a difficult task. Critical concerns by staff are very 
common sense and understandable:

     Am I safe, is my family safe?
     Where am I going to work and for how long?
     Am I protected from liability and workman's compensation 
issues?
     Am I trained to recognize and treat the disease or injury?
     If I take off work, will I be compensated?
     What is my specific job action, where do I fit within the 
chain of command?
     Am I qualified and trained to do the job?
     Do I have any physical limitations or restrictions that 
prevent me from responding?

    Federal, State or private medical staffs that provide medical care 
as their full or part-time employment should be provided opportunities 
to train, exercise and drill for a wide variety of all hazards 
catastrophic events during the course of their employment.
    One major objective for staffing would be to recruit volunteers 
before an incident occurs. This allows the opportunity to verify 
credentials, issue IDs, educate and train, and to participate in 
exercises and drills. The completion of the ESAR-VHP program would be 
valuable.
    Interstate regionalization is also a tool for filling in the 
critical gap between local, State and Federal response.
    To fill this gap in Northern New England, the Northern New England 
Metropolitan Medical Response System (NNE MMRS) functions as a 
coordinating resource for Maine, New Hampshire, and Vermont in 
preparing for and responding to the health and medical consequences of 
a mass casualty event affecting the tri-state region. When the national 
MMRS program was founded in 1996, the intention was to mitigate 
casualties from terrorist events using weapons of mass destruction by 
improving and coordinating planning efforts within metropolitan areas. 
Recent events, such as Hurricane Katrina and fears of an Avian Flu 
Pandemic, have underscored the need to improve planning and response 
efforts for natural disasters and disease epidemics nationally.
    The population of the three States exceeds 3 million with 52.6 
percent of residents residing in rural areas. Major population centers 
and seasonal tourist attractions within the region represent 
vulnerabilities for terrorist attacks. Furthermore, all three States 
share borders with Canada, necessitating close cooperation across an 
international boundary. Maine and New Hampshire both have active 
seacoasts, busy with commercial and leisure vessels.
    In addition to the threats to northern New England, the region must 
be concerned with terrorism and disease epidemics occurring in southern 
New England. Due to geography, in the event of a mass casualty incident 
in the urban areas of southern New England, it is likely that the tri-
state region will provide surge capacity for victims of the event. 
While some patients may be legitimately transported to northern 
hospitals, there is a distinct possibility that tens of thousands of 
individuals might flee the urban areas, overwhelming resources in the 
northern States and potentially spreading disease. There is also a need 
to be prepared to act on alerts from the Boston BioWatch program.
    (1) A large gap exists in trained health care workers to staff 
community-based health care facilities including alternative care 
centers, immunization and prophylaxis clinics and isolation and 
quarantine facilities. Basic issues such as liability, workman's 
compensation, personal and family protection, education and training, 
motivation and sustainability are high priorities for this group of 
health care personnel.
    Sub-state regionalization and inter-state regionalization are two 
useful tools that can fill the critical gap between local and State 
response, and the Federal response. Critical health care staff, medical 
equipment and supplies and pharmaceuticals may be available within 
neighboring communities or adjoining States. An example of interstate 
regionalization is the Northern New England Metropolitan Medical System 
which provides a planning mechanism and response capability for Maine, 
New Hampshire and Vermont.
    The Federal Government should provide concise planning guidance and 
technical information to communities that outline critical response 
capabilities. Common structures within States and across State lines 
allows for familiarity and cost effectiveness. A common structure would 
allow for seamless integration of staff, equipment and supplies
    (2) Significant logistical support for a massive Federal response 
should be through the Department of Homeland Security. This would 
enable close support of multiple agencies within DHS, as well as with 
DOD. DHHS and DHS should identify strengths and weaknesses within their 
agencies, and combine efforts to insure a rapidly mobile and competent 
medical response system. To optimally support the Federal response, a 
solid foundation in affected States and communities is needed to 
maintain an effective response capability. Strong medical direction at 
the senior level should direct the field deployment, response and 
logistical support.
    (3) Private health care delivery systems should be utilized as 
resources during the time of emergency and incentives should be in 
place for preparing for and responding to these emergencies. There 
should not be penalties or loss of income for private healthcare 
systems participating in emergency response. Participation of private 
health care can be easily added at the sub-state and community level.

    Senator Burr. Your written statements are invaluable to us 
and we have looked at those. I probably will stay away from 
some of that because there are some loose ends that I would 
like to wrap up in the 15 minutes that I have got with you.
    I think that your membership on NDMS response entity is a 
unique opportunity that we have to better understand, not 
necessarily today, but as we go through this process, I hope 
you will make yourself available to us as we talk about this 
relocation and, more importantly, how it is then structured. I 
think that this is not simply another Washington attempt to 
redesign the deck chairs. It is to create a robust and 
responsive entity with its focus on health response, and the 
threat, and not to hope that on any given day with any given 
situation, that these different pieces sort of come together. 
It should be a planned response, because they are all part of 
one unit and it is merely a question of how much of that unit 
you turn on.
    I am curious with the exercise you went through in New 
Jersey, given that you ended up with a distribution at the post 
offices, was the mail delivered that day?
    Dr. Gougelet. Well, as I said, it was a virtual reality 
event. Nothing was delivered that day----
    Senator Burr. But had you not decided on post offices as 
the distribution point, the mail would have been delivered that 
day, wouldn't it?
    Dr. Gougelet. It may have been. I mean, certainly in some 
jurisdictions in the State.
    Senator Burr. In all likelihood, you could have done the 
distribution given the choices you made, in 1 day, utilizing 
the same entity that you chose but utilizing it in a different 
capacity. Versus the post offices, you could have used the home 
delivery. I only point that out to you because I want to share 
that we have looked at every potential option that exists in 
this country for distribution. I think at the end of the day, 
we can come up with a consensus on a lot of the structural 
changes that are necessary and we will pass the test of 
workability.
    The one question that I have yet to figure out the answer 
to is, under numerous situations, how do we distribute what it 
is that we have got, and have we explored the use of the U.S. 
Postal Service as it relates to national distribution? We have 
looked at Wal-Mart and Home Depot and Lowe's that do this with 
great proficiency. I think it is safe to say, we do not have 
the answer yet that gives us the assurance there is one thing 
that we can turn to that gives us the capacity to do that. I 
think we are convinced that we have to answer that question 
before we complete this reauthorization, if not in total, in 
part, and that there be a quest to fill in the rest of that 
gap, which I think probably will exist.
    But I think many in the Federal Government have overlooked 
that capability that exists every day in this country, and that 
is that across the country, the mail is delivered every day, 
and in all likelihood, that person that delivers it, Richard, 
is the only one that knows actually how many people live in 
that house. It is not the Census Bureau, it is the postman.
    Dr. Bresnitz. If I could just make a comment on that, I got 
to know the local postal officials quite well during 2001 and I 
got an education about the U.S. Postal Service and labor-
management relationships in the U.S. Postal Service. It is 
sticky in many cases and I would only urge those at the top to 
understand that those who are the postal carriers and postal 
workers are not necessarily ones that have bought into such a 
system. I think that it is true that upper management has done 
that, but I am not so sure that at the local level, given the 
scenario that might play out in an attack, given that many of 
these carriers would require security and just that alone might 
give them hesitancy to participate in something like that. And 
so at the end of the day, even though postal leadership might 
think that this could work, I would want to know from the local 
people whether they would consent to doing something like that.
    Senator Burr. Feel certain that we have drilled down to the 
point that we understand the challenges that even that as a 
distribution choice present to us. I think it is safe to say 
that for a pandemic model, where HHS would model in 35 or 40 
percent of the individuals as no shows, all of a sudden, that 
choice is eliminated because you are looking for total coverage 
and that is conditional on a given person who shows up on a 
given day. You can fill in to a certain degree, but you can't 
fill in the 35 or 40 percent scenario that we have been 
presented. So I think we are truly trying to deal within the 
variances of the likelihood of what we are going to experience 
so a sufficient answer actually does meet the needs of whatever 
the threat is.
    Let me--yes, sir?
    Dr. Inglesby. On that point, I think, just if I could 
endorse your potential enthusiasm for using the Nation's great 
distributors that already give these kinds of medicines and 
vaccines out on a regular basis, I think there is a lot of 
evidence that the leaders of the major retail chains in the 
country would be interested in doing this if it became more 
clear how they could get involved. They have the physical 
plants. They have the parking lots. They can provide some 
modicum of security and they give out medicines and vaccines 
all the time, every day, but they have not, for the most part, 
been included in any kind of strategic thinking on that. But if 
I had to put my nickel down on some new huge operation that 
already exists that we could tap, I think that would certainly 
be worth doing, to put my nickel on.
    Senator Burr. I can safely assure you that we have looked--
--
    Dr. Inglesby. You have done it.
    Senator Burr. We have left no stone unturned as it relates 
to at least exploring what our options are.
    Let me ask you, if I can, what would be the greatest needs 
of a hospital in the event of a mass casualty incident?
    Dr. Inglesby. Well, the thing that would change the game 
entirely obviously would be vaccine. If we can't get vaccine, 
we jump down three or four levels to having to deal with a 
pretty terrible situation. So absent vaccine, hospitals are 
going to be in desperate need of the personal protective 
equipment that keeps health care workers--that gives health 
care workers the best chance to keep from being infected. They 
are going to need to have caches of anti-virals, if they are 
available, and a communications system which tells them what is 
going on elsewhere in the State, what is going on in the 
Governor's office, what is going on at CDC, because right now, 
most hospitals are pretty much autonomous entities which are 
competing across the street, which don't necessarily have a lot 
of connections. It depends on the State. New Jersey may be 
different. In some places, it may be stronger, but in many 
places, hospitals are entirely separate from the public health 
apparatus and have only kind of moderate personal connections.
    So they need to know what is going on. They need to have 
situational awareness about what is happening, where the 
medicines are, is there more coming, where are the patients 
that are sick, what is the overall sense of the State 
leadership. You need to have personal protective equipment.
    Senator Burr. Tom, the average hospital could last how long 
without being resupplied on the essentials?
    Dr. Inglesby. It depends on the kind of crisis, but I think 
some hospitals have already purchased Tamiflu and have 
purchased as many masks as they can get from Kimberly Clark or 
other suppliers. But there are sharp limits even now for 
hospitals who want to spend their own money on this.
    Senator Burr. I guess I am drilling down to just the 
basics, the basic supplies that a hospital has. How long can 
they maintain the treatment of patients if there are not new 
supplies coming in the door?
    Dr. Inglesby. The basics? So if you had complete or 
interruption of the supply chain for the typical needs of a 
hospital, probably a couple of days at the most. Most of them 
operate in just-in-time in most different areas of 
infrastructure. And if they lose one of them, if they lose 
electricity like they did in Louisiana, or if they lose water, 
or if they lose medical gases, then parts of their operation go 
down completely.
    Senator Burr. Rick, you talked about the surge capabilities 
designed for Boston, of 500 beds by a number of different 
methods, that the partnership was able to come up with. Did you 
ever model how long you could maintain that surge capacity to 
500 beds?
    Mr. Serino. We have had numerous tabletop drills, ERT 
summits. The most recent was a couple of months ago when we had 
over 350 people all in the room. To answer that, I am actually 
going to go back to what you were just asking about--hospitals 
and an individual hospital. One thing that we have found is 
that the hospitals initially were individual, and what we have 
done is bring them together. We have looked at the medical 
community as the medical community, including EMS, hospitals, 
public health and community health centers, which prove to be a 
very great asset in the city and also in rural areas, having 
the local community health centers or whatever they are called 
in their area in order to be part of a system. Having that as 
part of a system, having a seat, as they do, on the city's 
Emergency Operations Center, one for each one of those sit 
together so that 2 days out, when supplies start to dwindle 
down and there aren't enough medications or medical supplies in 
the hospital, that it is not a hospital requesting that, that 
they go through a centralized, organized at the city level, and 
then bumping that up so it can then be distributed in an 
organized manner rather than one hospital asking for one thing, 
another hospital asking for the same thing, somebody else 
asking for something else.
    We have tested that. That has worked, and it is important 
in order to do that, and I think that probably the most 
critical asset in the hospitals is not necessarily the 
equipment that is going to run out in 2 days. I think it is the 
people----
    Senator Burr. You have highlighted a couple of times this 
partnership that was created, not just within the family of 
medical. I would imagine that for the purposes of the DNC 
convention that that probably included law enforcement, it 
included----
    Mr. Serino. It included law enforcement at all levels and--
--
    Senator Burr. Let me ask you, what were the most difficult 
problems that you encountered as you tried to set up the 
agreements between all these entities.
    Mr. Serino. Lawyers. I say that in a room full of lawyers, 
but----
    [Laughter.]
    I think that probably one of the problems, aside from the 
lawyers, was trying to actually get people to understand the 
concept of what we wanted to do, and once we got people, and 
especially the CEOs, because we had the disaster coordinators, 
the ER staff all brought into it and it was how we were going 
to get everybody into it and it was the mayor, Mayor Menino, 
who was actually able to bring, you know, the CEOs together and 
to say, this is a priority.
    Senator Burr. I open this to anybody who would like to take 
a shot at it. I think everybody mentioned that there was a 
need, a necessity to tailor the needs of a response team to an 
area in which they are deployed and better integrate the 
Strategic National Stockpile with local responders. From the 
local perspective, how can we at the Federal level facilitate 
this increased integration? I think this is vital as we begin 
to create this framework that we know, what is the trigger?
    Dr. Gougelet. Well, you know, I believe the direction from 
the Federal Government in terms of what this framework should 
look like, should give a clearer understanding at the local 
level of what is expected in terms of response. For example, I 
think that when we did the smallpox planning several years ago, 
when we were given some specific criteria, you know, your total 
population immunized in 10 days, that was really the first time 
we got specific numbers and guidance and timeframe from the 
Feds in terms of what the local community should be doing, 
because obviously, with the smallpox epidemic or incident, the 
Federal Government wouldn't be involved in that. So this was 
the first time I think that the local responsibilities were 
thrust--or responsibilities were thrust upon the local 
communities.
    So the guidance from the Federal Government would be 
important, and then performance criteria and funding follows 
that. So we are talking about basic structures only in local 
communities or regions of local communities to stand up a 
capability, and then by testing those and reinforcing that 
financially and everything, I think is a reasonable thing to 
do.
    Senator Burr. Am I wrong to believe that we should create a 
public health floor that is the same in every community, not a 
ceiling, but a floor, that you need the confidence of knowing 
whether you are in the town you are in or whether it is 30 
miles down the road that the capabilities to some minimal level 
exist within the public health infrastructure in that 
community?
    Dr. Gougelet. Actually, I think you are correct in assuming 
that that is what we need. I mean, having this common framework 
doesn't necessarily--we tell them who is in charge in each 
community, what building to use, what is going to be the lead 
group, how many organizations should be at the table. I mean, 
those things are characteristics that the communities can 
determine on their own. But I really do believe we need that 
ground framework to get things going.
    Dr. Bresnitz. I would agree, as well, and I think most 
State and local health officials would, also. There are 
national public health practice standards, and we are not 
talking just about emergency preparedness but standards for 
public health in general. Those standards have been around for 
a few years. A number of States have taken those standards and 
adapted them to their own specific requirements at the State 
level.
    In New Jersey, for example, we actually have regulations in 
place, adopted a couple of years ago, that require local health 
departments to do an assessment of their capabilities and the 
gaps and then basically develop plans to move forward with 
basically improving their public health capabilities. The issue 
always comes down to, okay, so we have identified the gaps. Now 
where are the bucks to actually fill the gaps?
    Senator Burr. You see the difficulty that we have got in 
trying to create a national framework to operate within. If, in 
fact, community by community that public health piece changes 
from a standpoint of its capabilities, you can't plug it in in 
an overall template where it works the same or has some 
expanded capacity based upon local input, but there has got to 
be a minimal, as I see it, force to integrate them into any 
type of national model.
    Dr. Bresnitz. Agreed, and I would say that all public 
health agencies at the local level would like to be at that 
level, whatever that floor is, as you put it. The issue is, how 
do they get to that floor and beyond?
    Dr. Inglesby. Can I make a comment on that?
    Senator Burr. Yes.
    Dr. Inglesby. You asked before, how can the Federal 
Government respond? I think, to local triggers in a crisis. At 
UPMC during Katrina--Pennsylvania was entirely unaffected by 
Katrina--the CEO and the leadership of UPMC attempted to put 
its entire fleet of helicopters, 500 medical personnel, and 
beds--like countless institutions across the country, a similar 
experience. Over a week, it could not figure out a way to get 
into the Federal Government or into local or State governments 
in Louisiana to give any of it. They tried to knock on every 
door they could get.
    Now, maybe it was UPMC's own lack of familarity with the 
government, but volunteering was too hard on an institutional 
basis and on an individual basis. There were volunteers around 
the country who wanted to--health care volunteers who wanted to 
get involved, but they saw multiple new systems being set up on 
the fly, multiple credentialing systems, complete uncertainty 
about whether they would be covered from being sued.
    I think simple consolidation and clarity and simplicity in 
terms of what HHS could do. If you could find a way to say, 
this is where the volunteers should call. This is where 
interested institutions should call. There are a lot of things 
going on, but if we could kind of bring them together--ESAR-
VHP, MRC, the Public Health Civilian Corps, the Commissioned 
Corps, I think there are just too many small pieces and they 
are too far out across government. They are in DHS. They are in 
CDC. They are in HHS. They are in HRSA. I think we could bring 
them together, make it more simple and say, one-stop shopping.
    Senator Burr. Unfortunately, the clock has gotten me and I 
can assure you I could sit here for another hour and read 
through some questions. I hope you will allow me to do some, as 
well as other members, in writing.
    I think that is the opportunity we have, to take all of 
those different pieces and, No. 1, figure out which ones could 
be moved, which ones are absolutely crucial to our capabilities 
to respond and should be moved, and then the last test will be 
is there a willingness to fight the battle of the impact of 
that on Federal agencies. When you move responsibilities, as 
you know, there is a budget that goes along with them and 
budgets are very protected in Washington within certain 
agencies.
    Truly, this is an attempt on the part of the bipartisan 
subcommittee to look at how it should be designed and what the 
makeup should look like for us to respond in the best possible 
scenario. We will struggle between our inability to supply 
enough money--I think all of you know that--but I would refer 
to it a little bit differently. I would tell you that there is 
a short-term piece and there is a long-term piece.
    Short-term will always be driven by the urgency of the 
threat, and I think it is evident as to the investment we have 
made in a very short period of time in pandemic anti-viral 
vaccine research, preparation, versus the known threats that we 
have got out there today where there is not that sense of 
urgency. Therefore, there is not that quick injection of cash.
    My belief is, short-term as these threats or other threats 
emerge, we will respond to those short-term, and it is 
important that those dollars be used in a very effective way in 
the overall design of what it is we have put together. Long-
term, we have to be a partner just like you are partners with 
local entities that make up that successful response 
capability. And in long-term successful partnerships, there has 
to be, No. 1, a clearly-defined goal, and there has to be 
accountability for how one uses the money to, in fact, 
accomplish it.
    I sort of put you and everybody else on notice that I think 
one of the absolute essential requirements of this legislation 
and this subcommittee is to come up with the appropriate 
accountability piece that assures us that the right things are 
being invested in, and No. 2, ensures you and all the partners 
of the local entities that, over time, those resources that are 
needed for this function to take place will, in fact, be in 
place.
    I alluded to the first panel that one of the striking 
differences that existed in the Gulf Coast was a State that 
chose to put the majority of their Federal dollars in their 
surge capacity and a State that chose to put a majority of 
their dollars in their preparation and actual practice of their 
preparedness plan. As a result, you have two distinctly 
different outcomes between Mississippi and Louisiana.
    That is not to fault one and to highlight another. It is to 
say that in that case, we provided the choice. In the case of 
one, they chose wrong. Surge did them no good when the 
facilities that they built up were no longer available. I think 
that there is a lesson there that the subcommittee will go down 
and look at first-hand so that we can try to figure out a way 
not to design choices that might not be appropriate long-term 
into the structure of what it is we think we need in place.
    I will have on my wall, if you want to come by my office 
any time after today, ``Volunteering was hard.'' You have 
termed what I have been trying to tell Federal agencies since 
Katrina and before Katrina. We almost make volunteerism for 
anything where the Federal Government is involved impossible, 
and I think Senator Hatch alluded to it. I think Senator Harkin 
was on the fringes of it. We have to figure out a way to make 
volunteerism easy. We have to figure out a way to recruit 
individuals to commit to volunteer. If not, we can handle some 
of the threats that our communities are going to be faced with, 
but I will assure you there is a handful of threats, many of 
which we don't know what they are today, that will come at us 
as a country and a world in the future that we will not be able 
to handle if, in fact, we have not answered that one specific 
challenge.
    So on behalf of the subcommittee and the chairman and the 
ranking member, let me thank you for your willingness to be 
here. Hopefully, as this year goes on, we will consult with you 
on the product that we are trying to produce even more. Thanks.
    Senator Burr. This hearing is adjourned.
    [Additional material follows.]








                          ADDITIONAL MATERIAL

        Response to Questions of Senator Burr by Richard Serino
    Question 1. Effective medical response to a national catastrophe 
requires a sufficient number of medical personnel. Establishing 
alternative care sites will only be effective if they are staffed with 
trained health care providers. Currently, the Federal Government 
possesses several mechanisms to support this activity--NDMS, ESAR-VHP, 
Medical Response Corps, and the Commissioned Corps. How should the 
recruiting, credentialing, training, and managing of permanent and 
temporary Federal health care providers best be accomplished? How can 
the Federal Government best organize and deploy health care providers 
to assist in the response to a national emergency?
    Answer 1. The staffing issues that will arise during a medical 
crisis are some of the most challenging surge planning issues that 
local, State and Federal officials face. The programs in place to 
address these challenges represent a good start in the effort to 
provide adequate trained staff, however these programs must be expanded 
and coordinated. Specifically, the National Disaster Medical System 
must be expanded and better supplied; the Emergency System for Advanced 
Registration of Volunteer Health Professionals must be fully 
implemented and expanded; and the Medical Reserve Corps must be fully 
funded and supported. Additionally, it is essential to promote and 
assist local efforts to address surge capacity needs.
    The National Disaster Medical System must be expanded and 
adequately supported. The Disaster Medical Assistance Teams (DMAT) are 
primarily local and regional organizations that can be federalized 
during a crisis. For the most part, the DMATs are managed in States 
that face a regular need for medical surge capacity. While this often 
means that the teams are very well trained, it also means that during 
the time of a crisis teams are being pulled from locations where the 
personnel are still needed. For example, many of the Florida teams that 
responded to the Gulf Coast had just recently been involved in 
hurricane response in their own jurisdictions. Furthermore, the current 
structure of the DMATs, mandating a ``three-deep'' format, still does 
not provide adequate depth to insure full mobilization. The depth is 
not uniform across all specializations and thus leads to teams with 
significant gaps. The DMAT teams need to be expanded in numbers and in 
distribution. Through funding and other incentives, all States should 
be encouraged to help establish teams, and those teams should have 
sufficient depth to field well-rounded medical organizations during a 
crisis.
    While federalized assets such as the DMATs provide one critical 
surge resource, volunteers will provide the bulk of any medical 
response during a sustained crisis. The credentialing and organization 
of these volunteers provides an ongoing and unique challenge. While 
programs such as the Emergency System for Advanced Registration of 
Volunteer Health Professionals (ESAR-VHP) are steps in the right 
direction, they have yet to make a significant impact on the local 
level. The program is only in its very initial stages of rollout and it 
does not address many of the broader credentialing issues likely to 
come up during a crisis. ESAR-VHP must be fully implemented and 
expanded in conjunction with the Medical Reserve Corps, but it must 
also be supplemented with a broader national initiative. The Federal 
Government must push for a way to achieve universal credentialing for 
medical professionals involved in disaster response. If there is even 
the slightest chance of responding to a crisis, the individual must 
have pre-existing credentials and these must be recognizable across 
local and State boundaries. A credentialing program could include a 
universal symbol added to a driver's license or an additional national 
card issued during the time of initial credentialing.
    Additionally, volunteer organization remains a distinct challenge. 
The Medical Reserve Corps must be completely funded. While surge 
capacity is a universally recognized issue, the funding for the Medical 
Reserve Corps is constantly threatened. The program must be expanded 
through more effective recruitment, advertising, and improved training. 
The program should also be organized in conjunction with further 
efforts.
    Finally, in Boston, one of our great successes has been the 
Metropolitan Medical Response System staff sharing agreement. The MMRS 
agreement applies to staff and equipment and establishes that 
participating institutions cover liability and compensation for their 
staff, whether it is to help the city or another health care facility. 
Furthermore, the sending institution guarantees the staffs' 
credentials. The agreement has been implemented three times, twice for 
immunization clinics for Hepatitis A outbreaks and once during 
Hurricane Katrina. Efforts like the MMRS agreement provide the basis 
for expanded surge capacity and can serve as a model for State and 
Federal efforts.
    Once our volunteer programs are guaranteed long-term support, they 
need to be integrated into a comprehensive response plan. Those with 
experience, specifically the DMATs and the military will always best 
perform local response at the site of a disaster. Shelters and overflow 
hospitals are perfect places to Incorporate ESAR-VHP and medical 
reserve corps volunteers. If leadership and organization can be 
incorporated from the various hospitals, as our MMRS staff sharing 
agreement has done in Boston, these groups will be up and running 
faster. Additionally, if we are to guarantee these volunteers will show 
and be able to perform to their maximum capacity then we must guarantee 
that their workers compensation and liability protection is covered. 
Finally, these groups can provide added service at vaccination clinics 
and during the reception of displaced persons.

    Question 2. The medical preparation for, and response to disasters 
requires significant logistical support--medical supplies, 
pharmaceuticals, transportation, medical evacuation, etc. What is the 
most effective way to optimally support a Federal medical response? 
Which Federal agency should take the lead?
    Answer 2. During a large-scale medical response to a crisis, the 
primary logistical challenge is not the initial one, but the immediate 
follow-on response. Specifically, in addressing the needs of the 
National Disaster Medical System and the Disaster Medical Assistance 
Teams, the medium term logistical support requirements must be re-
examined.
    DMATs are specifically designed to deploy with a 72-hr supply of 
materials. One of the great successes of the DMATs was the initiative 
to provide all teams with dedicated trailers for pre-packaged 
deployment. This, however, has not solved the issue of supply, both in 
terms of immediate needs and longer-term requirements. Many DMATs are 
unable to sustain sufficient supplies for many types of deployments. In 
particular, there remain outstanding equipment requirements that must 
be addressed. While these needs are specific to each team, for example 
some Massachusetts teams lack environmental control units for their 
medical tents, it creates a larger problem during a deployment, 
critical time is spent trying to acquire or borrow needed equipment. 
Furthermore, while the teams do deploy with a 72-hour supply, the 
follow-on for this supply is inadequate. One suggestion is to develop 
additional DMAT caches such that a replacement 72-hour cache is 
immediately deployed behind a DMAT team. This way, as a team runs out 
of supplies, they need not spend critical time tracking down specific 
items, but will always have a complete additional stock of supplies 
waiting to fill in needs.
    Since the DMATs were incorporated into FEMA, logistics have 
improved: they now have emergency pharmaceutical caches, trucks, 
warehouse space, and a radio cache ready for deployment. However, there 
is still much to be done. For example, in the Katrina response, 
providers found that only certain antibiotics could be used for soft 
tissue wounds because of regional variation in the bacteria. FEMA 
logistics was unable to process this change from the usual antibiotic 
cache even after several weeks. Clearly, we need strong logistics, with 
a medical background.
    Logistical needs are not confined to the DMATs. The Federal 
Government must find a way to better address equipment needs during a 
surge incident. The National Pharmaceutical Stockpile and the Strategic 
National Stockpile are critical assets, however, they are not well 
integrated into local response capabilities. While the need for 
confidentiality and security in these caches is understandable, they 
are only useful if the people who use the equipment know what they will 
find and are familiar with its use. Federal and local agencies must 
find a way to coordinate the security needs of these stockpiles with 
the practical needs of efficient deployment.

    Question 3. National medical preparation and response to mass 
casualties is dependent upon integrating multiple components, including 
a largely private health care delivery system. What steps must be taken 
to foster a more coordinated response that includes a strong public-
private partnership?
    Answer 3. Federal, State, and local governments must pursue every 
opportunity to incorporate the medical community into planning and 
training. The worst possible outcome is for people to be exchanging 
business cards on the day of a crisis. It is only through ongoing 
coordination, exercises, and trainings that full integration is 
maintained. In Boston, we have had real success by insuring the medical 
community has a seat in homeland security planning and discussions, by 
including the medical community in regular exercises and drills, and by 
providing effective training that spans disciplines.
    Locally, we have learned the value of existing relationships. Our 
successes in medical planning come from bridging the gap between a 
well-integrated medical community and the public safety and Federal 
agencies that play central roles in homeland security and emergency 
preparedness. As the result of extensive experience working with the 
Conference of Boston Teaching Hospitals to manage disaster planning in 
the city as well as more mundane day-to-day emergency planning, there 
is an existing group of local officials and private organizations that 
have worked hand in hand for years. By establishing and carrying 
forward committees and organizations that address planning and response 
issues, the people who will have to work together in a disaster already 
know each other. Furthermore, by including the medical community in the 
planning process, many people have learned how important such planning 
is. There is now a seat for the medical community on the U.S. 
Attorney's Joint Terrorism Task Force and the Anti-Terrorism Advisory 
Council. The medical community is an integral part of Boston's Homeland 
Security planning, and while some formal structures are still missing, 
they now have a seat at the table.
    One of our lessons learned is that the medical community needs to 
be considered part of the critical infrastructure. Communications, 
infrastructure protection, and integration into existing emergency 
management structures are all tasks that flow from this acceptance of 
the private medical infrastructure into the public response community.
         Response to Questions of Senator Burr by Ellen Embrey
    Question 1a. Effective medical response to a national catastrophe 
requires a sufficient number of medical personnel. Establishing 
alternative care sites will only be effective if they are staffed with 
trained health care providers. Currently, the Federal Government 
possesses several mechanisms to support this activity--National 
Disaster Medical System (NDMS), ESAR-VHP, Medical Response Corps, and 
the Commissioned Corps. How should the recruiting, credentialing, 
training, and managing of permanent and temporary Federal health care 
providers best be accomplished?
    Answer 1a. The medical response to a national catastrophe begins 
first and foremost with State and local first responders. The Federal 
Government must anticipate and be prepared to rapidly respond if State 
and local governments are not able to mount an effective response, even 
before a formal request for Federal assistance is received. The 
mechanisms to provide Federal health care provider resources are 
through the National Disaster Medical System (NDMS), the Emergency 
System for Advance Registration of Volunteer Health Professionals 
(ESAR-VHP), the Medical Reserve Corps, and the Public Health Service 
Commissioned Corps. However, the Defense Department, to the extent 
health care resources and providers are not deployed on other global 
missions, can provide additional health providers to supplement the 
workforce. DOD needs to synchronize these assets and capabilities with 
the overarching coordinating body. Specific recommendations include:

    i. Recruiting

    1. Recruiting from retired or currently unemployed but qualified 
volunteer providers within the community and State.
    2. Making use of reserve military medical and nursing providers and 
other responders, as well as an expanded group of allied health 
professionals, such as veterinarians, dentists and dental auxiliary 
providers, pharmacists, and students in training.

    ii. Credentialing

    1. HHS, working with State government and specialty/professional 
associations, needs to continue to build a robust and comprehensive 
Federal health care providers database.
    2. HHS needs to continue to research regulations to cross-
credential Federal providers, including DOD providers during times of 
crisis/national emergency.
    3. HHS needs to continue to develop ESAR-VHP and other databases to 
allow for online validation of credentialing requirements to facilitate 
rapid certification of medical professional volunteers.
    4. HHS attorneys need to work with the States' Attorneys General to 
ensure federally credentialed providers do not require additional 
credentialing when deployed within any given individual State.

    iii. Training

    1. HHS needs to determine what types of providers are required in 
catastrophic events and provide guidance to the remainder of the ESF#8 
partners and recommended training standards.
    2. Train an expanded group of providers, such as veterinarians, 
dentists and other allied health professionals to provide ``triage'' 
and basic care requirements.
    3. Create a system to train a pool of non-medical responders to 
support health and medical care operations (e.g., military personnel at 
sea are all trained in BLS and basic responder care to act as first 
responders). Note: Although the ``best possible care'' will be 
delivered during a mass casualty event, the ``standards of care'' may 
be different than what can be provided during daily routine scenarios.
    4. Determine processes to reallocate providers from non-emergency 
care and non-emergency sites to emergency response assignments and from 
unaffected regions to affected regions (this will involve identifying 
skill sets of each practitioner group [such as paramedics and nurse 
midwives], so as to optimize reassignment potential).

    Question 1b. How can the Federal Government best organize and 
deploy health care providers to assist in the response to a national 
emergency?
    Answer 1b. Collectively, Federal agencies, including DOD, have many 
trained medical personnel who can be called upon to respond to a mass 
casualty event. The problem is a need for improved coordination, 
consistency in policies and procedures, and regular simulations/
exercises. The National Incident Management System should be used to 
affect clear command and control and provide improved situational 
awareness to the healthcare situation at the site of the disaster. 
Specific recommendations include:

    i. HHS should work with the ESF#8 partners, including DOD, to 
develop capabilities-based concepts vice pre-established units (e.g. 
Federal Medical Stations).
    ii. DOD should include HHS, VA and DHS/FEMA and other ESF#8 
partners in its determination of capabilities, including interagency 
deployable capabilities
    iii. DOD should work the Services and the interagency partners to 
develop and more broadly apply Unit Type Codes (UTC's) which identify 
capabilities, team readiness, and deployment status.

    Question 2a. The medical preparation for, and response to disasters 
requires significant logistical support--medical supplies, 
pharmaceuticals, transportation, medical evacuation, etc. What is the 
most effective way to optimally support a Federal medical response?
    Answer 2a. i. DHS/FEMA needs to provide the overall construct of 
logistical support to include the infrastructure available for public 
health and medical requirements.

    ii. Establish an ESF#8 logistics coordinator (like the Strategic 
National Stockpile) that will:

    1. Establish medical supply chains and support capabilities to 
prioritize, acquire, distribute, and redirect assets based on HHS 
guidance.
    2. Monitor and report the status of critical medical materiel and 
items during emergency response operations.
    3. Coordinate logistics support from commercial suppliers.
    4. Assess emergency response capability.
    5. Plan and build deployable sets.

         a. Plan and coordinate return, re-use, or disposal of assets 
        after the contingency is over.

    iii. The idea of establishing a Federal Medical Materiel 
Coordination Group (FMMCG) was originally proposed as a result of Sept. 
11, 2005 and the anthrax scare when one Federal agency negotiated their 
own contract price for antibiotics, but failed to include other Federal 
agencies. The FMMCG is designed to establish procedures for 
coordinating and allocating critical medical materiel items among the 
different Federal agencies seeking the same products in the event of an 
all-hazards catastrophe. Once established, this coordination group 
would represent the Federal agencies engaged in acquisition and 
management of medical materiel to support emergency operations. It 
would focus on defining criteria that elevates allocation decisions for 
medical materiel items across Federal agencies. This group would work 
to develop the above requirements to feed into the existing FEMA 
logistics management and distribution processes. The lessons learned 
from Hurricane Katrina for medical logistics could be resolved with 
this FMMCG.
    iv. Patient movement and evacuation of displaced persons should be 
removed from this function and ``managed'' through ESF#1/Department of 
Transportation (DOT). All requests should come through the NRCC to 
determine the most efficient use of transportation assets, to include 
the use of pre-existing transportation contracts to move patients that 
do not require medical care during movement. A national (Federal, 
State, local) system for evacuee and patient transport, regulation, and 
tracking should be developed that begins at the incident site, follows 
the evacuee/patient to intermediary locations (e.g., hospitals, nursing 
homes, rehabilitation centers, etc.), to final disposition (e.g. home). 
Transportation assets at Federal, State and local levels need to be 
coordinated and visible, and related communication needs to occur 
throughout all levels.

    Question 2b. Which Federal agency should take the lead?
    Answer 2b. i. DHS/FEMA Logistics should develop standard processes 
to accomplish the above for all ESF's.
    ii. DHHS should be the lead Federal agency, as detailed in ESF#8. 
DHHS should plan, exercise and coordinate a medical response. If the 
catastrophe is beyond their capability, DOD could be considered to 
assume the lead. However, this should be a Presidential decision based 
on:

    1. the extent to which State and local first responders are 
effectively managing the situation,
    2. the extent to which Federal civilian responders are able to 
effectively manage the problem,
    3. the nature of existing relationships in the jurisdictions 
affected, and
    4. the nature of existing relationships between the military and 
the States affected.

    Question 3. National medical preparation and response to mass 
casualties is dependent upon integrating multiple components, including 
a private health care delivery system. What steps must be taken to 
foster a more coordinated response that includes a strong public-
private partnership?
    Answer 3. Steps begin with aggressive regional, State, and private 
sector coordination between the ESF#8 functional lead and appropriate 
parties. Lack of pre-event planning can result in an ineffective, 
inefficient and dysfunctional response. Local healthcare providers and 
agencies should be knowledgeable of local requirements and assets 
available on scene. The Federal response should be geared to supporting 
those requirements and filling gaps at the State or regional levels, 
when requested.
    Under the NORTHCOM model, Joint Regional Medical Planning Offices 
(JRMPOs) exist in peacetime to coordinate medical support to local and 
State civilian authorities. This effort is being expanded by FEMA and 
DHHS and should continue to be expanded to include all Federal agencies 
and the private sector.

    i. Messages should be developed that clearly include the private 
health care industry as our partner.
    ii. Incentives should be developed to recruit private industry and 
academia to provide assistance.
    iii. Reimbursement strategies for loss of elective surgery (the 
main source of hospital income) need to be developed to ensure 
solvency.
    iv. Legal considerations should be evaluated to ensure the ability 
to view all types of patient data, location, status, etc. during a 
catastrophic event.
    v. HHS, in coordination with the other NDMS partners, should re-
evaluate NDMS to potentially expand its functions to include the 
private sector and make recommendations on the adequacy and feasibility 
of utilizing the current NDMS structure to support catastrophic events. 
Inclusion of other ESF#8 supporting Departments/agencies within NDMS 
should be considered (e.g. DOT).

    [Whereupon, at 12:07 p.m., the subcommittee was adjourned.]

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